The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?

Bounding pulse, hypertension, and distended neck veins.

Thready pulse, hypotension, and chest or back pain.

Urticaria, itching, and wheezing.

Chills, fever, and tachycardia.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The correct answer is a) because a bounding pulse, hypertension, and distended neck veins are signs of fluid overload, which can occur during blood transfusions, especially in older adults.

Choice B reason: A thready pulse, hypotension, and chest or back pain are more indicative of shock or severe anemia rather than fluid overload.

Choice C reason: Urticaria, itching, and wheezing suggest an allergic reaction, not fluid overload.

Choice D reason: Chills, fever, and tachycardia can indicate a febrile or transfusion reaction but are not specific to fluid overload.

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Correct Answer is ["B","C","E"]

Explanation

Choice A reason: Limiting computer screen time is good general advice but is not specific to preventing blindness from glaucoma.

Choice B reason:

The correct answer is b) because following the prescribed regimen for eye drops helps manage intraocular pressure, which is crucial for preventing optic nerve damage in glaucoma.

Choice C reason:

The correct answer is c) because reporting any changes in vision can help detect progression of glaucoma early and allow for timely intervention.

Choice D reason: Maintaining a diet high in vegetables is good for overall health but is not directly related to preventing blindness from glaucoma.

Choice E reason:

The correct answer is e) because regular eye pressure checks help monitor the effectiveness of treatment and prevent progression of glaucoma.

A. Arthritic joint changes and chronic pain. B. Lower back pain and hypotension. C. Acute rhinitis and nasal stuffiness. D. Delayed painful rash with urticaria.

Correct Answer is B

Explanation

Choice A reason: Arthritic joint changes and chronic pain are not related to an ABO incompatibility reaction.

Choice B reason:

The correct answer is b) because lower back pain and hypotension are signs of a hemolytic transfusion reaction, which requires immediate intervention.

Choice C reason: Acute rhinitis and nasal stuffiness are not related to an ABO incompatibility reaction.

Choice D reason: Delayed painful rash with urticaria can indicate an allergic reaction but is not specific to a hemolytic transfusion reaction.

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The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a new diagnosis of glaucoma is concerned about going blind. To help prevent blindness due to glaucoma, the nurse should instruct the client to implement which action(s)? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

Correct Answer is B

Explanation

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