A nurse is assessing an older adult client who is receiving 2 units of packed RBCs. Which of the following manifestations should indicate to the nurse that the client is experiencing circulatory overload?

Hypotension

Flattened jugular veins

Lethargy

Bounding pulse

Answer and Explanation

The Correct Answer is D

Rationale:
A. Hypotension: Circulatory overload typically causes hypertension rather than hypotension due to increased blood volume and pressure. Hypotension would be more consistent with a different transfusion reaction such as anaphylaxis or septic shock.

B. Flattened jugular veins: Jugular vein distention, not flattening, is a classic sign of circulatory overload. Distended neck veins indicate elevated central venous pressure from fluid excess.

C. Lethargy: While lethargy may occur with various conditions, it is not a specific or early sign of circulatory overload. More immediate symptoms include respiratory distress and cardiovascular changes.

D. Bounding pulse: A bounding pulse is a key sign of circulatory overload, reflecting increased stroke volume and elevated intravascular volume. It often occurs alongside hypertension, dyspnea, and jugular vein distention, especially in older adults with compromised cardiac function.

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Correct Answer is B

Explanation

Rationale:

A. The nurse provides wound care to a client at the time promised to the client: Providing care as scheduled reflects reliability and professionalism, but it does not involve speaking up for or securing specific services in the client's best interest, which defines advocacy.

B. The nurse refers a client who has chronic obstructive pulmonary disease for palliative care services: This demonstrates advocacy by ensuring the client has access to specialized care that supports comfort, dignity, and symptom management—especially important in progressive, life-limiting illness.

C. The nurse declines to inform a client's neighbor about the client's prognosis: This action protects client confidentiality and privacy, which is ethically correct, but it does not represent active support or promotion of the client's needs or preferences.

D. The nurse files an incident report regarding a medication error: Filing an incident report supports patient safety and institutional accountability. However, it does not reflect direct advocacy, as it does not involve pursuing specific care or services for the client.

A. Oral temperature of 37.2° C (99° F) B. Clear drainage on the dressings C. Drain output 75 mL in 4 hr D. Decreased bowel sounds in all quadrants of the abdomen

Correct Answer is B

Explanation

Rationale:
A. Oral temperature of 37.2° C (99° F): This is a normal postoperative temperature and does not indicate infection or any other complication. Mild elevations in temperature are expected after surgery.

B. Clear drainage on the dressings: Clear drainage, particularly if it is watery and not tinged with blood, may indicate cerebrospinal fluid (CSF) leakage. This is a serious complication of spinal surgery and requires immediate evaluation to prevent infection and further neurological issues.

C. Drain output 75 mL in 4 hr: This amount of drainage is within normal limits for the early postoperative period, depending on the surgeon's parameters. It is not inherently concerning unless it becomes excessive or has abnormal characteristics.

D. Decreased bowel sounds in all quadrants of the abdomen: Decreased bowel activity is common after surgery due to anesthesia and immobility. It is expected in the immediate postoperative period and not necessarily a sign of a complication unless prolonged.

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A nurse is assessing an older adult client who is receiving 2 units of packed RBCs. Which of the following manifestations should indicate to the nurse that the client is experiencing circulatory overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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