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 B

No explanation

A. Monitor the client for weight loss. B. Advise the client about increased dry mouth. C. Inform the client of the adverse effect of diarrhea. D. Check the client for increased hypopigmentation under the patch.

Correct Answer is B

Explanation

Advise the client about increased dry mouth. Transdermal clonidine can cause xerostomia, or dry mouth, due to a decrease in salivary secretion. The nurse should advise the client to maintain good oral hygiene and to increase fluid intake to prevent oral and dental problems.

An explanation for incorrect choices:

A. Weight loss is not a common adverse effect or risk associated with transdermal clonidine.

C. Diarrhea can occur with transdermal clonidine, but it is not a common adverse effect or risk.

D. Hypopigmentation is rare with transdermal clonidine; it is more common with corticosteroids.

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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 in an urgent care facility is collecting data from a client who was stung by a wasp. Which of the following findings indicates the client is experiencing anaphylaxis?

Correct Answer is B

A nurse is assisting with the plan of care for an older adult client who has a new prescription for transdermal clonidine. Which of the following information should the nurse include in the plan of care?

Correct Answer is B

Explanation

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