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 C

Explanation

If a client reports pain and informs the nurse that pain medications are not an option for managing their pain, the nurse can oﬀer non-pharmacological interventions such as a back massage to help relieve the client's pain. This is an appropriate response by the nurse.

a. Telling the client that the pain medication will work if they just give it a chance is not an appropriate response as it dismisses the client's concerns and preferences.

b. The nurse should not recommend that the client take any herbal remedies without first consulting with the healthcare provider.

d. Asking the client why they think pain medication is not going to help them may be appropriate in some situations, but it is not necessarily the best initial response. The nurse should first oﬀer non- pharmacological interventions to help relieve the client's pain.

A. Palpate the brachial pulse site. B. Discontinue palpation of the brachial pulse. C. Inﬂate the blood pressure cuﬀ to 30 mm Hg beyond where the brachial pulse was last felt. D. Deﬂate the blood pressure cuﬀ slowly until the brachial pulse is detected.

Correct Answer is A, C, B, D

Explanation

First, the nurse should palpate the brachial pulse site to locate the artery. Next, the nurse should inﬂate the blood pressure cuﬀ to 30 mm Hg beyond where the brachial pulse was last felt. The nurse should then discontinue palpation of the brachial pulse and deﬂate the blood pressure cuﬀ slowly until the brachial pulse is detected. This is the point at which the systolic blood pressure can be read.

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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 reports a pain level of 5 on a scale from 0 to 10. The client informs the nurse that pain medications are not an Option for managing pain. Which of the following is an appropriate response by the nurse?

Correct Answer is C

Explanation

A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuﬀ to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)

Correct Answer is A, C, B, D

Explanation

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