A nurse is monitoring a client who is undergoing a blood transfusion of packed RBCs. The nurse should recognize that which of the following findings indicates fluid overload?
Fever
Dyspnea
Pruritus
Bradycardia
The Correct Answer is B
Choice A rationale
Fever is not typically a sign of fluid overload. It’s more commonly associated with a transfusion reaction, which could indicate an immune response to the transfused blood.
Choice B rationale
Dyspnea, or difficulty breathing, can be a sign of fluid overload. When the body has too much fluid, it can put pressure on the lungs, making it harder to breathe.
Choice C rationale
Pruritus, or itching, is not typically a sign of fluid overload. It may be a sign of an allergic reaction to the transfusion.
Choice D rationale
Bradycardia, or a slow heart rate, is not typically a sign of fluid overload. In fact, tachycardia, or a fast heart rate, is more common as the heart works harder to pump the excess fluid.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Intermittent abdominal pain is not typically associated with total parenteral nutrition (TPN) or burn injuries.
Choice B rationale
Increased serum glucose levels can occur with TPN due to the high glucose content of the solution. This should be monitored closely, especially in patients with burns, who may have altered glucose metabolism.
Choice C rationale
Absent bowel sounds are not typically associated with TPN or burn injuries.
Choice D rationale
Decreased calcium levels are not typically associated with TPN or burn injuries.
Correct Answer is B
Explanation
Choice A rationale
Hypoactive bowel sounds in all four quadrants are not unusual in a patient one day postoperative following an appendectomy. This is because anesthesia and surgery can slow down the bowel movements temporarily.
Choice B rationale
Red streaks along the incision are a sign of infection. This could indicate cellulitis, a common skin infection that can be serious if left untreated. The red streaks are often warm to the touch and may be accompanied by other signs of infection such as fever, pain, and swelling.
Therefore, the nurse should report this finding.
Choice C rationale
Serosanguineous drainage at the incision site is not uncommon in the first few days after surgery. It is a mixture of blood and serum and is usually light pink to blood-tinged in color. However, if the drainage is heavy, or if it continues for more than a few days, it could be a sign of a problem such as infection or poor wound healing.
Choice D rationale
A temperature of 37.2 C (99 F) is within the normal range for body temperature. A slight elevation in temperature can be expected after surgery due to the body’s inflammatory response to the surgical trauma.
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