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 A
Explanation
Choice A rationale
Limiting sodium intake to no more than 2,000 milligrams per day is a recommended strategy to prevent hypertension. Excessive sodium intake can increase blood pressure by causing the body to retain fluid, which increases the volume of blood and subsequently, blood pressure.
Choice B rationale
While regular exercise is beneficial for overall health, the statement “I should exercise for 30 minutes three times per week” may not be sufficient for hypertension prevention. The American Heart Association recommends at least 150 minutes per week of moderate-intensity aerobic activity or 75 minutes per week of vigorous aerobic activity, or a combination of both, preferably spread throughout the week.
Choice C rationale
Eating fish once per week is not a specific recommendation for preventing hypertension. While fish can be a good source of lean protein and omega-3 fatty acids, it does not directly relate to blood pressure control.
Choice D rationale
The statement “With a BMI of 30, I should maintain my current weight” is incorrect. A BMI of 30 falls into the category of obesity, which is a risk factor for hypertension. Weight loss is recommended for hypertension prevention and control in overweight and obese individuals.
Correct Answer is C
Explanation
Choice A rationale
Loosening the screws while cleaning the pin sites is not recommended. The screws are tightened to a specific pressure to ensure the halo vest is secure and provides the necessary immobilization.
Choice B rationale
The nurse should also provide education regarding changing positions at least every 2 hours to reduce pressure injuries.
Choice C rationale
Halo-vests are managed and monitored during spinal outpatient clinics and can be removed during this clinic appointment.
Choice D rationale
The halo ring should never be used to lift or reposition the client because it is directly attached to the skull. Pulling on the ring could cause serious injury or dislocation.
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