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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
When planning an educational conference about informed consent, the nurse should include information about the potential risks of the procedure. Informed consent is a process in which the client is provided with information about a medical procedure or treatment, including its potential risks and benefits, so that they can make an informed decision about whether to proceed.
Option a is incorrect because after signing the informed consent, the client still has the right to refuse the procedure.
Option c is incorrect because it is not the nurse's responsibility to explain the procedure when obtaining informed consent; this is typically done by the healthcare provider performing the procedure.
Option d is incorrect because a nursing student cannot witness an informed consent; only a licensed healthcare professional can do so.
Correct Answer is A
Explanation
When providing end-of-life care for a client, the nurse should encourage the client to make choices regarding their hygiene. This allows the client to have some control over their care and can help them feel more comfortable.
Option b is incorrect because offering the client sips of a citrus flavored soda may not be appropriate for all clients and should be based on individual preferences and needs.
Option c is incorrect because positioning the client supine in bed may not be comfortable for all clients and should be based on individual preferences and needs.
Option d is incorrect because suctioning the client's airway every hour may not be necessary and should be based on individual needs.
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