A nurse is monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has fluid overload?

Blood in the tubing close to the insertion site

Chills, fever, and generalized discomfort

Pallor, sweating, and discomfort at the insertion site

Dyspnea, headache, and increased blood pressure

Answer and Explanation

The Correct Answer is D

A. Blood in the tubing close to the insertion site: This indicates a possible issue with the IV but not fluid overload specifically.
B. Chills, fever, and generalized discomfort: These symptoms may suggest an infection or reaction but are not specific to fluid overload.
C. Pallor, sweating, and discomfort at the insertion site: These could indicate a local reaction or issue with the IV site but not fluid overload.
D. Dyspnea, headache, and increased blood pressure: These symptoms are indicative of fluid overload, as the body reacts to excessive fluid with symptoms such as difficulty breathing (dyspnea), increased blood pressure, and headaches.

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 C

Explanation

A. Serum glucose and a Complete Blood Count: While a complete blood count (CBC) is useful in assessing overall health, serum glucose is less relevant in the context of renal disease. The focus should be on kidney function rather than glucose levels.
B. Arterial blood gas and coagulation tests: Arterial blood gas (ABG) and coagulation tests may be important for other conditions, but they are not specifically targeted to evaluate renal function or related preoperative risks in renal disease.
C. Serum creatinine and a Basic Metabolic Panel: This is the correct choice as serum creatinine is a key marker of kidney function, and a Basic Metabolic Panel (BMP) provides information on electrolyte levels and overall metabolic status, which are crucial in evaluating the impact of renal disease on surgery.
D. Chest X-ray and cardiac enzymes: These tests are more relevant for evaluating cardiac function and lung status rather than directly assessing kidney function, which is the primary concern in the context of renal disease.

A. Continue monitoring the client. B. Increase nasal oxygen flow rate to 8 L C. Place the client in high Fowler's position. D. Notify the surgeon as soon as possible

Correct Answer is D

Explanation

A. Continue monitoring the client: The client's vital signs, pale and cool skin, and low urine output suggest potential hypovolemic shock or other serious postoperative complications, requiring more immediate intervention than just continued monitoring.
B. Increase nasal oxygen flow rate to 8 L: While increasing oxygen may be necessary, the primary concern is the underlying cause of the client's symptoms, which may require more immediate intervention.
C. Place the client in high Fowler's position: This position may be beneficial for certain conditions but does not address the underlying issues suggested by the vital signs and physical findings.
D. Notify the surgeon as soon as possible: This is the correct choice. The client's hypotension, tachycardia, pale and cool skin, and low urine output indicate potential complications that need immediate evaluation by the surgeon.

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 monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has fluid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a preoperative review of systems, the client reveals a history of renal disease. This finding suggests the need for which relevant preoperative diagnostic tests?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

The nurse is educating a group of student nurses about the different types of anesthesia. The student demonstrates an understanding of the teaching when they state that a client would maintain a gag reflex with what anesthesia?

A nurse is caring for a client who had an abdominal hysterectomy. Which intervention best prevents postoperative thrombosis?

A client indicates to the nurse a pain level of 8 out of 10. The nurse notes the client has an order for morphine 4 mg IV Q 6 hr PRN for moderate to severe pain. The client's blood pressure is 80/54 mm Hg, respirations 10 breaths/min, and pulse 62 beats/min. Which action should the nurse take?

A nurse is monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has fluid overload?

The client is admitted with a serum sodium level of 110 mEq/L. What nursing intervention should be implemented?

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

A nurse is providing education in a community setting to several clients taking daily calcium supplements and encourages them to drink 2,500 mL of fluid daily. The nurse explains that this intervention is important to prevent which complication?