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
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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Related Questions
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.
Correct Answer is B
Explanation
After moving clients to a safe location, the next action the nurse should take is to pull the fire alarm. This will alert others in the building to the presence of a fire and activate the building's fire suppression systems.
Options a, c, and d are not the next actions the nurse should take. Using an extinguisher to put out the fire may be appropriate if the nurse has been trained to do so and if it is safe to do so. Closing the doors to client rooms can help to contain the spread of smoke and fire, but it is not the next action the nurse should take. Turning off electrical equipment in the room may help to prevent further ignition sources, but it is not the next action the nurse should take.
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