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?

Dyspnea

Fever

Pruritus

Bradycardia

Answer and Explanation

The Correct Answer is A

Fluid overload is a potential complication of blood transfusion, and dyspnea is one of the hallmarks of fluid overload. Other signs and symptoms of fluid overload include a headache, hypertension, jugular vein distention, rapid breathing, and tachycardia.

An explanation for incorrect choices:

B. Fever is generally not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a febrile non-hemolytic transfusion reaction.

C. Pruritus is typically not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as an allergic reaction.

D. Bradycardia is not typically associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a hemolytic transfusion reaction.

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Correct Answer is C

Explanation

Yankauer catheter. A Yankauer catheter is a suction device used for oral suctioning. It is important for this client to have access to a Yankauer catheter for safe and effective suctioning of secretions from the mouth.

Option A is incorrect because an Oropharyngeal airway is used to maintain or open the airway.

Option B is incorrect because the water-soluble lubricant is used for lubricating the suction catheter during suctioning.

Option D is incorrect because sterile gloves are not routinely needed for suctioning.

Reasons why the other options are not answered: Option A: An oropharyngeal airway is not used for suctioning but is used to maintain an open airway in an unconscious patient. Option B: Water-soluble lubricant is used for lubricating the suction catheter during suctioning. Option D: Sterile gloves are not routinely needed for suctioning.

A. Moderate amount of serosanguineous drainage on dressings B. Serum calcium level 9.2 mg/dL C. Report of a sore throat D. Oral temperature 39° C (102.2° F)

Correct Answer is D

Explanation

The correct answer is choice D. The nurse should identify an oral temperature of 39°C (102.2°F) as the priority finding in a client who is postoperative following a total thyroidectomy for hyperthyroidism. An elevated temperature can indicate infection, which is a risk after surgery. The nurse should report this finding to the provider immediately.

Choices A, B, and C are incorrect because moderate amount of serosanguineous drainage on dressings, serum calcium level 9.2 mg/dL, and report of a sore throat, respectively, are expected findings after a total thyroidectomy and do not require immediate action.

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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

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