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 B

Explanation

The correct answer is that the nurse should recommend the client to eat a light carbohydrate snack before bedtime. Eating a light carbohydrate snack before bedtime can help promote sleep by increasing the level of tryptophan in the brain, which can help induce sleep.

Options a, c and d are not appropriate interventions for insomnia. Taking a 30-min nap daily can disrupt nighttime sleep and worsen insomnia. Exercising 1 hr before bedtime can increase alertness and make it harder to fall asleep. Drinking a cup of hot cocoa before bedtime can also disrupt sleep due to its caﬀeine content.

A. Explain the techniques of esophageal speech. B. Schedule a support session for the client. C. Determine the client's reading ability. D. Review the use of an artificial larynx with the client. E. None F. None

Correct Answer is C

Explanation

A. Explain the techniques of esophageal speech.Esophageal speech is one method of communication but is learned later through speech therapy. Not the immediate priority.

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.After surgery, the client will not be able to speak initially. Knowing if the client can read and write allows the nurse to provide a communication method (such as writing or using a communication board) to meet immediate needs, especially related to airway, pain, and care.

D. Review the use of an artificial larynx with the client.An electrolarynx is an option but is introduced later in recovery. It is not the immediate concern before surgery.

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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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