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 C

Explanation

Choice A reason: While the chest x-ray report is important, it is not as immediately critical as a low potassium level.

Choice B reason: The surgical consent form is important but can be addressed quickly before surgery.

Choice C reason:

The correct answer is c) because a preoperative serum potassium level of 2.8 mEq/L is dangerously low and requires immediate correction to avoid cardiac complications during surgery.

Choice D reason: A pulse oximeter reading of 96% is within normal limits and does not require immediate action.

A. Hypotension and venous pooling in the extremities. B. Pain and a burning sensation upon urination and hematuria. C. Profuse diaphoresis and severe, pounding headache. D. Reports of chest pain and shortness of breath.

Correct Answer is C

Explanation

Choice A reason: Hypotension and venous pooling in the extremities are not typical of autonomic dysreflexia. Autonomic dysreflexia usually results in hypertension due to an exaggerated autonomic response to a stimulus such as a full bladder. This condition is characterized by severe, uncontrolled hypertension rather than hypotension.

Choice B reason: While pain and a burning sensation upon urination and hematuria can be related to a urinary tract infection or bladder issue, they are not specific to autonomic dysreflexia. Autonomic dysreflexia presents with symptoms that result from the body's exaggerated response to the stimulus, such as severe headache and sweating.

Choice C reason:

The correct answer is c) because profuse diaphoresis (sweating) and a severe, pounding headache are hallmark signs of autonomic dysreflexia. This condition occurs in individuals with spinal cord injuries at or above the T6 level and is triggered by stimuli like a full bladder, causing a dangerous rise in blood pressure and severe autonomic responses.

Choice D reason: Reports of chest pain and shortness of breath are not typical signs of autonomic dysreflexia. While these symptoms may be concerning, they are not the primary indicators of this specific condition. The severe headache and sweating are more indicative of autonomic dysreflexia.

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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

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?

Correct Answer is C

Explanation

A client who had a C-5 spinal cord injury 2 years ago is admitted to the emergency department (ED) with the diagnosis of autonomic dysreflexia secondary to a full bladder. Which assessment finding should the nurse expect this client to exhibit?

Correct Answer is C

Explanation

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