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

Explanation

Choice A reason: Avoiding driving is important but not the most critical instruction.

Choice B reason:

The correct answer is b) because drinking plenty of water helps flush the bladder, reduce the risk of infection, and prevent blood clots.

Choice C reason: Eliminating spicy foods may help with overall comfort but is not as important as maintaining proper hydration.

Choice D reason: Clamping the catheter during a shower is not necessary and could cause complications.

A. Place an indwelling urinary catheter and attach a bedside drainage unit. B. Give a prescribed analgesic for temperature above 101°F (38.3°C), orally. C. Send the client to x-ray for a flat plate of the abdomen. D. Insert a nasogastric tube (NGT) and attach to low intermittent suction (LIS).

Correct Answer is D

Explanation

Choice A reason: Placing an indwelling urinary catheter is not immediately relevant to the client's symptoms.

Choice B reason: Giving an analgesic for a fever does not address the underlying issue of bowel obstruction.

Choice C reason: Sending the client to x-ray can help diagnose the issue but is not the first action to relieve symptoms.

Choice D reason:

The correct answer is d) because inserting a nasogastric tube and attaching it to low intermittent suction helps decompress the stomach and relieve symptoms of bowel obstruction.

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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

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Explanation

Correct Answer is D

Explanation

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