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 A
Explanation
When checking a client's blood pressure, the nurse should use a cuff with a width that is about 60% of the client's arm circumference. This will help to ensure that the cuff fits properly and provides an accurate reading.
Options b, c, and d are not correct. The cuff should be applied over the client's brachial artery, which is located in the antecubital fossa. The client should sit with their arm resting at the level of their heart, not above it. The pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.
Correct Answer is C
Explanation
The correct answer is that the client can apply lotion to their feet if they avoid the area between their toes. Moisturizing the feet can help prevent dry skin and cracking, which are common problems for people with diabetes. However, it is important to avoid applying lotion between the toes, as this can create a moist environment that promotes the growth of fungus and bacteria¹.
Options a, b and d are not correct statements by the client that indicate an understanding of proper foot care for diabetes. Using a pumice stone to soften calluses on the feet, going barefoot just in the house and using a heating pad when feet are cold are not recommended practices for people with diabetes.
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