A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

Bradycardia

Flattened neck veins

Fever

Crackles in the lungs

Answer and Explanation

The Correct Answer is D

This is because crackles are a sign of fluid overload in the lungs, which can occur when a client receives too much IV fluid. Fluid overload can cause pulmonary edema, which is a life threatening condition that reduces oxygen exchange in the lungs. Some other signs and symptoms of fluid overload include rapid weight gain, swelling in the arms, legs and face, high blood pressure and shortness of breath.

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Correct Answer is A

Explanation

A tracheostomy is a surgical opening in the neck that allows air to enter the lungs through a tube called a tracheostomy tube. The tube has two parts: an outer cannula that stays in place and an inner cannula that can be removed for cleaning. The tracheostomy ties are used to secure the tube to the neck and prevent it from falling out. They should be adjusted to allow one finger to fit snugly underneath, so that they are not too tight or too loose.

A. The client's background health history B. The number of visitors client had during shift C. The times for routine vital sign measurements D. The type of transmission-based precautions in place

Correct Answer is D

Explanation

The nurse should include in report type of transmission-based precautions in place for client who has shingles, which is contact precautions. This information is essential for preventing spread of infection to other clients and staff members. The client's background health history, number of visitors during shift, and times for routine vital sign measurements are not specific or relevant information for this client's condition and do not need to be included in report.

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A nurse is assessing a client who is receiving continuous IV fluids through a peripheral IV. Which of the following findings indicates to the nurse that the client is experiencing fluid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse at a long-term care facility is providing change-of-shift report to an oncoming nurse about a client who has shingles. Which of following information should nurse include in report?

Correct Answer is D

Explanation

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