A nurse is evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?

Heart rate 60/min

Skin warm and dry

Respiratory rate 30/min

Tenting skin turgor

Answer and Explanation

The Correct Answer is C

Choice A reason: A heart rate of 60/min is within normal range and does not indicate fluid overload, which may present with tachycardia due to increased cardiac workload. This finding is more consistent with normal physiology or hypovolemia, making it incorrect for identifying fluid overload.
Choice B reason: Skin warm and dry suggests normal hydration or dehydration, not fluid overload, which typically causes edema or moist skin. Dry skin indicates fluid deficit, not excess, making this finding irrelevant and incorrect for assessing fluid overload in this client.
Choice C reason: A respiratory rate of 30/min indicates tachypnea, a sign of fluid overload due to pulmonary edema from excess IV fluids. Fluid in the lungs impairs gas exchange, increasing breathing effort, aligning with clinical manifestations of overload, making this the correct finding.
Choice D reason: Tenting skin turgor indicates dehydration, not fluid overload, as it reflects reduced skin elasticity from fluid loss. Fluid overload causes edema, not tenting, making this finding opposite to the expected presentation and incorrect for this scenario.

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 B

Explanation

Choice A reason: The lactation amenorrhea method is effective only up to 6 months postpartum, and only if exclusive breastfeeding and amenorrhea are maintained. It is not reliable for 12 months, so this statement is inaccurate, making it incorrect for contraception teaching.
Choice B reason: Placing the transdermal contraceptive patch on the upper arm or back ensures proper adhesion and absorption. This aligns with manufacturer guidelines for effective contraception, making it a correct and appropriate instruction for postpartum clients seeking reliable methods.
Choice C reason: A diaphragm used before pregnancy may no longer fit due to pelvic changes post-delivery. It requires refitting 6 weeks postpartum, so continuing use without adjustment is ineffective and risky, making this incorrect.
Choice D reason: Starting oral contraceptives immediately after delivery is not recommended, especially for breastfeeding mothers, due to risks like reduced milk supply or thromboembolism. Initiation typically begins 3-6 weeks postpartum, making this incorrect and unsafe.

A. Apply the gel to the client’s genital region. B. Instruct the client to have his testosterone checked in 1 week. C. Advise the client to wait 1 hr before showering or swimming. D. Instruct the client to apply the gel every other day.

Correct Answer is C

Explanation

Choice A reason: Applying testosterone gel to the genital region is contraindicated, as it increases irritation and absorption variability. It should be applied to clean, dry skin on the shoulders, upper arms, or abdomen to ensure safety and efficacy, making this action incorrect and unsafe.
Choice B reason: Checking testosterone levels in 1 week is premature, as steady-state levels typically require 2-4 weeks to stabilize. Monitoring too early may yield inaccurate results, leading to improper dose adjustments. This timing is not standard, making it an incorrect instruction.
Choice C reason: Advising the client to wait 1 hour before showering or swimming ensures adequate absorption of testosterone gel through the skin. Premature water exposure can wash off the gel, reducing efficacy. This aligns with manufacturer guidelines, making it the correct action.
Choice D reason: Applying testosterone gel every other day is incorrect, as daily application maintains consistent hormone levels for hypogonadism treatment. Alternate-day dosing disrupts therapeutic levels, reducing effectiveness. Daily use is standard, making this instruction inappropriate for proper administration.

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 evaluating a client who received intermittent IV fluids. Which of the following findings indicates the client has a fluid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is postpartum and interested in information about contraception. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is preparing to administer testosterone gel to a client who has hypogonadism. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is providing education to a client who is reviewing a consent form for a surgical procedure. Which of the following statements by the client indicates an understanding of the consent?

A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching?

A nurse is performing an abdominal assessment as part of a client’s comprehensive physical examination. Which of the following is the final step the nurse should perform?

A nurse is preparing a sterile field for a client who requires a sterile procedure. Which of the following actions should the nurse plan to take?

A nurse is providing dietary teaching to a client who has a new diagnosis of irritable bowel syndrome. Which of the following recommendations should the nurse include?

A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of post-traumatic stress disorder? (Select all that apply)

A nurse preceptor is observing a newly licensed nurse caring for a client on a medical-surgical unit. Which of the following actions by the newly licensed nurse requires further instruction by the preceptor?

A nurse is providing teaching to a parent of a child who has Varicella. Which of the following statements should the nurse include in the teaching?