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?

Dyspnea

Fever

Pruritus

Bradycardia

Answer and Explanation

The Correct Answer is A

Fluid overload is a potential complication of blood transfusion, and dyspnea is one of the hallmarks of fluid overload. Other signs and symptoms of fluid overload include a headache, hypertension, jugular vein distention, rapid breathing, and tachycardia.

An explanation for incorrect choices:

B. Fever is generally not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a febrile non-hemolytic transfusion reaction.

C. Pruritus is typically not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as an allergic reaction.

D. Bradycardia is not typically associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a hemolytic transfusion reaction.

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Correct Answer is C

No explanation

A. Obtain blood pressure readings using the client's right arm. B. Limit range-of-motion exercises with the affected arm. C. Keep both arms below the level of the client's heart. D. Use the client's left arm to obtain blood samples.

Correct Answer is D

Explanation

The client had a right radical mastectomy, which can lead to lymphedema, a buildup of fluid that can cause swelling in the arm. Using the client's left arm to obtain blood samples can help prevent injury to the affected arm and reduce the risk of lymphedema. Obtaining blood pressure readings with the client's left arm is also recommended. Range-of-motion exercises are important to prevent stiffness, and elevating the affected arm can help reduce swelling.

A: Obtaining blood pressure readings with the client's right arm can cause injury and increase the risk of lymphedema.

B: Limiting range-of-motion exercises can lead to stiffness and may not prevent lymphedema.

C: Keeping both arms below the level of the client's heart can help reduce swelling, but does not directly prevent lymphedema.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is D

Explanation

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