The practical nurse (PN) is assessing a client who received a large volume of IV fluids over a short period of time. Which finding (s) should the PN expect this client to exhibit? Select all that apply.
Dependent edema.
Inelastic skin turgor.
Complaints of thirst.
Tachycardia.
Moist lung sounds.
Correct Answer : A,D,E
A. Dependent edema:
Fluid volume overload leads to increased hydrostatic pressure in capillaries, causing fluid to shift into the interstitial spaces, particularly in dependent areas like the legs, ankles, and sacrum.
B. Inelastic skin turgor:
Inelastic skin turgor is typically a sign of dehydration, not fluid overload. Overhydrated clients often have taut, stretched skin, not decreased elasticity.
C. Complaints of thirst:
Thirst is a compensatory mechanism for dehydration or hypernatremia, not for fluid overload.
D. Tachycardia:
Excess fluid increases the workload of the heart, which can lead to an increased heart rate as a compensatory mechanism.
E. Moist lung sounds:
Fluid volume overload can cause pulmonary congestion, leading to crackles or moist lung sounds due to fluid accumulation in the alveoli.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The parent's version of the injury is different from the child's version: Inconsistent histories are a red flag for abuse and require further investigation.
B. The child has several abrasions on the chest and legs: Abrasions alone can occur with falls; they are not specific to abuse without suspicious patterns or locations.
C. The child looks at the floor when answering the nurse's questions: Avoidance may be due to shyness or fear but is not conclusive for abuse.
D. The parent refuses to answer questions about family history: While uncooperative behavior may be concerning, it is less direct than inconsistent injury accounts.
Correct Answer is D
Explanation
A. Inform the manager that the facility will have to assume responsibility for incidents related to staffing: This is confrontational and does not address immediate care needs.
B. Refuse to take charge and go home rather than risk working in an unsafe situation: Abandoning patients is unethical and could have legal consequences.
C. Assign some tasks usually performed by the additional PN to the UAP who is normally on the wing: UAPs cannot legally take on PN duties; this is unsafe.
D. Prioritize assessment of safety issues in addition to administration of daily medication: When short-staffed, prioritize safety and essential tasks to ensure client well-being.
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