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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse should begin by testing the client while they are wearing glasses, as this reflects their usual visual acuity. The nurse should document the smallest line that the client can read on the chart, not the largest. The nurse should position the client 6m (20 feet) away from the chart, not 3.3m (10 feet). The nurse should instruct the client to begin the assessment with one eye covered and then switch to cover the other eye.
Correct Answer is A
Explanation
False imprisonment. The rationale for this answer is that false imprisonment is the unlawful confinement of a person without consent or legal justification. The nurse violated the client's right to freedom of movement by placing him in restraints without a valid prescription or indication.
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