A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).

Crackles in lung bases.

Periorbital edema.

Swelling at the IV site.

Bounding radial pulse.

Flat neck veins when supine.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale:

Crackles in lung bases Crackles in the lung bases are often indicative of fluid accumulation in the lungs, which can occur in conditions like heart failure. These crackles are discontinuous and sound like "fine rales.”. They can be heard during inspiration and expiration.

Choice B rationale:

Periorbital edema Periorbital edema, or swelling around the eyes, can be a sign of fluid volume overload, especially in the context of an older adult receiving IV therapy. It suggests that excess fluid is accumulating in the body.

Choice D rationale:

Bounding radial pulse A bounding radial pulse is a sign of increased stroke volume and can occur when the heart is working harder to pump the increased blood volume associated with fluid overload.

Choice C rationale:

Swelling at the IV site Swelling at the IV site can be a local reaction and may not necessarily indicate fluid volume overload unless it is associated with other systemic signs.

Choice E rationale:

Flat neck veins when supine Flat neck veins when the client is supine are not typically associated with fluid volume overload. In fact, flat neck veins are more characteristic of hypovolemia. Now, let's address the final question.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale:

Restricting visitation is an essential intervention during an influenza outbreak in a long-term care facility. Influenza is highly contagious and can spread rapidly among residents and staff in a close environment like a long-term care facility. By limiting visitation, the facility can reduce the risk of introducing the virus from the outside and help contain the outbreak. This is a preventive measure to protect vulnerable residents from exposure to the virus.

Choice B rationale:

Providing prophylactic antibiotics for clients who have been exposed to influenza is not a recommended intervention. Influenza is caused by a virus, not bacteria, so antibiotics are ineffective in preventing or treating the infection. Antibiotics should only be used to treat bacterial infections, not viral ones. Inappropriate use of antibiotics can lead to antibiotic resistance and other adverse effects.

Choice C rationale:

Implementing airborne precautions for clients who have influenza is not typically necessary. Influenza primarily spreads through respiratory droplets when an infected person coughs or sneezes. Standard precautions, such as proper hand hygiene and wearing masks when in close contact with infected individuals, are usually sufficient to prevent the spread of the virus. Airborne precautions are typically reserved for diseases that are transmitted through the airborne route, like tuberculosis.

Choice D rationale:

Assigning healthcare personnel to nondirect care activities for 24 hours after developing influenza symptoms is not a recommended intervention. While it's important for healthcare personnel to stay home when they are sick to prevent the spread of the virus, 24 hours may not be a necessary duration. The standard guideline for healthcare workers with influenza is to stay home until they are fever-free for at least 24 hours without the use of fever-reducing medications.

A. "A headache indicates tolerance to the medication.”. B. "It sounds as if you are allergic to this medication.”. C. "A headache is a common adverse effect of this medication, but it will probably occur less often over time.”. D. "Your headache is probably a result of anxiety about the chest pain.”.

Correct Answer is C

Explanation

Choice A rationale:

Tolerance to nitroglycerin is not indicated by the presence of a headache. Nitroglycerin is a vasodilator used to relieve angina, and headaches can be a common side effect.

Choice B rationale:

Allergic reactions to nitroglycerin are rare, and a headache is not a typical symptom of an allergy to this medication.

Choice C rationale:

"A headache is a common adverse effect of this medication, but it will probably occur less often over time.”. This is the correct response. Nitroglycerin commonly causes headaches due to its vasodilatory effects. Patients often experience this side effect initially, but it tends to improve or occur less frequently with continued use. The nurse should educate the client about this and reassure them that the headaches should diminish over time.

Choice D rationale:

Anxiety may exacerbate chest pain, but it is not the likely cause of the headache. It is important to address the headache as a potential side effect of the medication.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is collecting data from an older adult who is postoperative and receiving IV therapy at 125 mL/hr. The nurse should identify that which of the following findings indicates the client is experiencing fluid volume overload? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with planning interventions for an influenza outbreak in a long-term care facility.Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse administered nitroglycerin sublingually to a client who has angina pectoris and experienced chest pain.The client states that his chest pain is relieved but now he has a headache.Which of the following responses by the nurse is appropriate?

Correct Answer is C

Explanation

The nurse is preparing to administer Tylenol to a client admitted with urination issues who also has difficulty sleeping (OSA). Which interaction is most important for the nurse to implement before leaving the client?

A nurse is collecting data from a client who has heart failure, prior to the administration of furosemide. For which of the following findings should the nurse withhold the medication?

A nurse is preparing to review discharge instructions with a client who has pulmonary tuberculosis.Which of the following information should the nurse include?

A nurse is reinforcing teaching about a heart-healthy diet with a group of clients who have hypertension. Which of the following statements by the clients indicates a need for further teaching?

A nurse is caring for a client whose arterial blood gas results show the following results:. pH: 7.2. PaCO2: 50 mm Hg. HCO3: 24 mEq/L. The nurse should identify the client is experiencing which of the following acid-base conditions?

A home health nurse is visiting a client who has COPD and is receiving oxygen at 2 L/min via nasal cannula.The client tells the nurse she has been having difficulty breathing.Which of the following actions is the nurse's priority at this time?

A nurse is reinforcing discharge teaching with a client about dietary sources of potassium. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is conducting a preoperative interview with a client who is scheduled for surgery.The client states that he takes acetylsalicylic acid 81 mg. by mouth daily.Prior to the client's upcoming surgery, the nurse should instruct the client to do which of the following?