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?

Fever

Crackles in the lungs

Bradycardia

Flattened neck veins

Answer and Explanation

The Correct Answer is B

Crackles in the lungs indicate that the client is experiencing ﬂuid overload. When there is an excess of ﬂuid in the body, it can accumulate in the lungs and cause crackles. The other

a. Fever is not a sign of ﬂuid overload.

c. Bradycardia (a slow heart rate) is not a sign of ﬂuid overload.

d. Flattened neck veins are not a sign of ﬂuid overload; distended neck veins may be a sign of ﬂuid overload.

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Correct Answer is D

Explanation

A. Explain the techniques of esophageal speech.Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.

B. Schedule a support session for the client.While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.

C. Determine the client's reading ability.This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.

D. Review the use of an artificial larynx with the client.This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.

A. Increased skin elasticity B. Reduced sweat production C. Increased production of oils D. Thickened outer layer of skin

Correct Answer is B

Explanation

The correct answer is that the nurse should expect to find reduced sweat production when performing a skin assessment on an older adult client. As we age, our skin gradually loses its ability to produce sweat and oil, which can result in dry skin¹.

Options a, c and d are not expected findings when performing a skin assessment on an older adult client. Increased skin elasticity, increased production of oils and thickened outer layer of skin are not typical age- related changes.

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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

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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