A nurse is assessing a client who is receiving continuous IV ﬂuids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing ﬂuid overload?

Fever

Crackles in the lungs

Bradycardia

Flattened neck veins

Answer and Explanation

The Correct Answer is B

Crackles in the lungs indicate that the client is experiencing ﬂuid overload. When there is an excess of ﬂuid in the body, it can accumulate in the lungs and cause crackles. The other

a. Fever is not a sign of ﬂuid overload.

c. Bradycardia (a slow heart rate) is not a sign of ﬂuid overload.

d. Flattened neck veins are not a sign of ﬂuid overload; distended neck veins may be a sign of ﬂuid overload.

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Correct Answer is C

Explanation

A. Explain the techniques of esophageal speech.Esophageal speech is one method of communication but is learned later through speech therapy. Not the immediate priority.

B. Schedule a support session for the client.While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.

C. Determine the client's reading ability.After surgery, the client will not be able to speak initially. Knowing if the client can read and write allows the nurse to provide a communication method (such as writing or using a communication board) to meet immediate needs, especially related to airway, pain, and care.

D. Review the use of an artificial larynx with the client.An electrolarynx is an option but is introduced later in recovery. It is not the immediate concern before surgery.

Correct Answer is ["480"]

Explanation

480 mL.

The client's total oral intake over the 4-hour period is 3 ounces of milk + 2 ounces of orange juice + 3 ounces of tea + 4 ounces of water = 12 ounces. Since there are approximately 30 mL in 1 ounce, the client's oral intake in mL is 12 ounces * 30 mL/ounce = 360 mL.

The client is also receiving dextrose 5% in 0.45% sodium chloride at a rate of 30 mL/hr by continuous IV infusion. Over a 4-hour period, the client will receive a total of 30 mL/hr * 4 hours = 120 mL from the IV infusion.

Therefore, the client's total intake for that 4-hour period is 360 mL (oral intake. + 120 mL (IV infusion) = 480 mL.

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A nurse is assessing a client who is receiving continuous IV ﬂuids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing ﬂuid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

Correct Answer is C

Explanation

Correct Answer is ["480"]

Explanation

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