A client is receiving IV fluids at 150 mL/hr. Which of the following findings indicates that the client is experiencing fluid overload?
Oliguria
Bradycardia
Dyspnea
Poor skin turgor
The Correct Answer is C
- A. Oliguria. This is incorrect because oliguria, or decreased urine output, is a sign of fluid volume deficit, not fluid volume overload.
- B. Bradycardia. This is incorrect because bradycardia, or slow heart rate, is not a typical sign of fluid volume overload, unless the client has a cardiac condition that affects the heart's response to fluid overload.
- C. Dyspnea. This is correct because dyspnea, or difficulty breathing, is a common sign of fluid volume overload, as excess fluid accumulates in the lungs and impairs gas exchange.
- D. Poor skin turgor. This is incorrect because poor skin turgor, or decreased elasticity of the skin, is a sign of dehydration, not fluid volume overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Limiting each of the client's visitors to 2 hours per day is not a necessary precaution for a client undergoing brachytherapy with a low-dose radiation implant. The duration of visitor stays does not directly impact the effectiveness of the treatment or the safety of the client.
Choice B rationale:
Instructing visitors to stay 1 m (3.3 feet) away from the client is not a standard practice for patients undergoing brachytherapy. Radiation safety protocols are in place to protect both the patient and visitors. However, the exact distance may vary based on the specific treatment and facility guidelines.
Choice C rationale:
Attaching a dosimeter to the client's gown is the correct action. A dosimeter measures the amount of radiation exposure received by the client. This information is crucial for healthcare providers to monitor the client's radiation dose, ensuring it stays within safe limits and effectively targets the cancer cells.
Choice D rationale:
Straining the client's urine is not directly related to brachytherapy with a low-dose radiation implant. This intervention is more relevant in situations where kidney stones or other urinary obstructions are suspected. It is not a standard practice for patients undergoing brachytherapy.
Correct Answer is A
Explanation
- A. Pink, frothy sputum is a characteristic finding of pulmonary edema, which is caused by fluid accumulation in the alveoli and interstitial spaces of the lungs. This impairs gas exchange and leads to hypoxia and respiratory distress.
- B. Bradycardia is not expected in pulmonary edema. The client is more likely to have tachycardia due to increased sympathetic stimulation and decreased cardiac output.
- C. Flushed, dry skin is not expected in pulmonary edema. The client is more likely to have pale, cool, and clammy skin due to peripheral vasoconstriction and decreased perfusion.
- D. Wheezing is not a specific finding of pulmonary edema. It may indicate bronchospasm or asthma, which are different conditions that affect the airways rather than the alveoli.
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