A nurse is monitoring a client who is undergoing a blood transfusion of packed RBCs. The nurse should recognize that which of the following findings indicates fluid overload?

Fever

Dyspnea

Pruritus

Bradycardia

Answer and Explanation

The Correct Answer is B

Choice A rationale

Fever is not typically a sign of fluid overload. It’s more commonly associated with a transfusion reaction, which could indicate an immune response to the transfused blood.

Choice B rationale

Dyspnea, or difficulty breathing, can be a sign of fluid overload. When the body has too much fluid, it can put pressure on the lungs, making it harder to breathe.

Choice C rationale

Pruritus, or itching, is not typically a sign of fluid overload. It may be a sign of an allergic reaction to the transfusion.

Choice D rationale

Bradycardia, or a slow heart rate, is not typically a sign of fluid overload. In fact, tachycardia, or a fast heart rate, is more common as the heart works harder to pump the excess fluid.

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Correct Answer is ["1.5"]

Explanation

Step 1: Identify the order. The order is for 15,000 units of heparin.

Step 2: Identify the available medication. The available medication is heparin 10,000 units/mL.

Step 3: Calculate the dose. To find out how many mL to administer, divide the number of units ordered by the number of units per mL. So, 15,000 units ÷ 10,000 units/mL = 1.5 mL. So, the nurse should administer 1.5 mL of heparin with each dose.

A. Elevate your legs on pillows when in bed. B. Apply a heating pad for 15 minutes twice per day. C. Begin an exercise program that includes walking. D. Wear knee-high support hose during the day.

Correct Answer is C

Explanation

Elevating the legs on pillows when in bed is not typically recommended for patients with peripheral arterial disease (PAD). This position can actually decrease arterial blood flow to the legs and worsen symptoms.

Choice B rationale

Applying a heating pad for 15 minutes twice per day is not a standard recommendation for managing PAD. While heat can increase blood flow, it can also lead to burns in patients with decreased sensation due to PAD1.

Choice C rationale

Beginning an exercise program that includes walking is often recommended for patients with PAD. Regular physical activity can improve symptoms of claudication (pain caused by reduced blood flow) and increase overall cardiovascular health.

Choice D rationale

Wearing knee-high support hose during the day is not typically recommended for patients with PAD. Compression stockings are more often used in the management of venous rather than arterial conditions.

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A nurse is monitoring a client who is undergoing a blood transfusion of packed RBCs. The nurse should recognize that which of the following findings indicates fluid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer heparin 15,000 units every 12 hr subcutaneously to a client who weighs 80 kg. Available is 10,000 units/mL. How many mL should the nurse administer with each dose?

Correct Answer is ["1.5"]

Explanation

A nurse is providing education to a patient who has been diagnosed with peripheral arterial disease. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reviewing a patient’s medical record.After reviewing the medical data, which of the following actions should the nurse plan to take?

A nurse is providing dietary education about general nutritional guidelines to a group of older adult patients. Which of the following statements, if made by a patient, would indicate an understanding of the teaching?

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