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: Altered tissue perfusion is important but not the primary concern in osteomalacia.

Choice B reason: Sleep pattern disturbance may occur but is not the highest priority.

Choice C reason:

The correct answer is c) because clients with osteomalacia have weakened bones and are at high risk for fractures, making injury prevention the highest priority.

Choice D reason: Risk of infection is important but not the primary concern in osteomalacia.

A. Chicken, rice, and wheat products. B. Lean beef, salads, and baked potatoes. C. Oatmeal, raisins, and fruit with skin. D. Potatoes, low-fat breads, and applesauce.

Correct Answer is C

Explanation

Choice A reason: While chicken and rice are healthy, they do not specifically address the benefits of fiber in cancer prevention.

Choice B reason: Lean beef is not recommended for reducing the risk of colon cancer, although salads and baked potatoes are healthy choices.

Choice C reason:

The correct answer is c) because oatmeal, raisins, and fruit with skin are high in fiber, which can help reduce the risk of colon and rectal cancers.

Choice D reason: Potatoes and low-fat breads are healthy but do not provide as much fiber as oatmeal, raisins, and fruit with skin.

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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

Which nursing problem has the highest priority when planning care for a client with osteomalacia?

Correct Answer is C

Explanation

Which group of foods is best for the nurse to recommend for clients with a strong family history of colon and rectal cancers?

Correct Answer is C

Explanation

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