A nurse is preparing to administer a transfusion of red blood cells to a client who has a history of heart failure. Which of the following manifestations would indicate that the client has fluid overload?
Dyspnea
Gastrointestinal bloating.
Weight loss of 4 pounds.
A blood pressure of 120/80.
The Correct Answer is A
A. Dyspnea is a common sign of fluid overload, especially in clients with heart failure.
B. Gastrointestinal bloating is not a typical manifestation of fluid overload.
C. Weight loss indicates fluid loss, not overload.
D. A blood pressure of 120/80 is normal and does not indicate fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While starch and protein are important, the key dietary modification is to reduce fat intake to minimize gallbladder stimulation.
B. Avoiding high-fat foods helps prevent biliary colic by reducing gallbladder contractions.
C. Fiber is beneficial for overall digestion but is not the primary focus for managing biliary colic.
D. Sodium restriction is not specifically related to managing biliary colic or cholecystitis.
Correct Answer is D
Explanation
A. IV fluids are essential to maintain hydration and support circulation in acute pancreatitis.
B. Bedrest helps reduce metabolic demand and discomfort.
C. Daily weighing helps monitor fluid balance and edema.
D. Clients with acute pancreatitis are typically NPO initially to rest the pancreas; introducing diet too early, even low-fat, is contraindicated until inflammation subsides.
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