A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

Weight loss

Decreased blood pressure

Decreased skin turgor

Crackles heard in the lungs

Answer and Explanation

The Correct Answer is D

A.   Incorrect. Weight loss is not a manifestation of fluid overload but rather of insufficient nutrition.
B.   Incorrect. Decreased blood pressure is not a manifestation of fluid overload but could indicate hypovolemia.
C.   Incorrect. Decreased skin turgor is a sign of dehydration, not fluid overload.
D.   Correct. Crackles heard in the lungs can indicate fluid overload in the lungs, also known as pulmonary edema. This is often caused by an excess of fluid in the body.

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Correct Answer is B

Explanation

The correct answer is choice b. “I will stop what I am doing and lie down.”

Choice A rationale:

Taking two 325 milligram aspirin tablets at the same time is not the recommended immediate action for chest pain. Aspirin can help in preventing blood clots, but it is not the first step in managing acute angina.

Choice B rationale:

Stopping activity and lying down is the correct initial response to chest pain. This helps reduce the heart’s workload and can alleviate the pain.

Choice C rationale:

Calling the provider after taking one dose of nitroglycerin is important, but it is not the first step. The client should first stop activity and lie down, then take nitroglycerin if prescribed.

Choice D rationale:

Holding the breath and bearing down (Valsalva maneuver) is not appropriate for managing chest pain and can actually increase the heart’s workload, potentially worsening the situation.

A. Witness the client signing a consent for transfusion. B. Obtain a large bore IV catheter. C. Ensure two nurses confirm the information on the blood label. D. Ensure the transfusion tubing is flushed with dextrose 5% in water. E. Explain to the client that transfusion reactions are not serious.

Correct Answer is ["A","B","C"]

Explanation

A. Correct. The nurse should witness the client signing a consent form for blood transfusion.
Informed consent is necessary for any medical procedure.
B. Correct. A large bore IV catheter is required for blood transfusion to ensure the smooth flow of blood and prevent clotting.
C. Correct. Two nurses should confirm the information on the blood label, including the client's identification and the blood type, to prevent errors.
D. Incorrect. Transfusion tubing is typically flushed with normal saline before attaching it to the patient. Flushing with dextrose 5% in water is not necessary or recommended.
E. Incorrect. It's important for the nurse to educate the client about potential transfusion reactions, as some reactions can indeed be serious. Providing accurate information helps the client understand the importance of monitoring for any signs of a reaction.

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A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with a client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

Correct Answer is B

Explanation

The nurse is reviewing the client's medical record. Procedures Planned endoscopy at 1300. The nurse is assisting with the care of the client prior to a blood transfusion. Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

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