The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?

Bounding pulse, hypertension, and distended neck veins.

Thready pulse, hypotension, and chest or back pain.

Urticaria, itching, and wheezing.

Chills, fever, and tachycardia.

Answer and Explanation

The Correct Answer is A

Choice A reason:

The correct answer is a) because a bounding pulse, hypertension, and distended neck veins are signs of fluid overload, which can occur during blood transfusions, especially in older adults.

Choice B reason: A thready pulse, hypotension, and chest or back pain are more indicative of shock or severe anemia rather than fluid overload.

Choice C reason: Urticaria, itching, and wheezing suggest an allergic reaction, not fluid overload.

Choice D reason: Chills, fever, and tachycardia can indicate a febrile or transfusion reaction but are not specific to fluid overload.

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Correct Answer is D

Explanation

Choice A reason: Warm, soft, moist, salmon-colored skin is not typical of Cushing's syndrome.

Choice B reason: Visible swelling of the neck, with no pain, is not specific to Cushing's syndrome.

Choice C reason: A husky voice and trouble with hoarseness are not typical of Cushing's syndrome.

Choice D reason:

The correct answer is d) because central-type obesity with thin extremities is a characteristic feature of Cushing's syndrome.

A. The nurse will demonstrate the procedure for accurate eye care. B. The client's blood pressure readings will be less than 160/90 mm Hg. C. The client's hemoglobin A1C will be less than 7% in 3 months. D. The nurse will encourage the client to walk thirty minutes every day.

Correct Answer is C

Explanation

Choice A reason: Demonstrating accurate eye care is important but is not a measurable outcome for managing diabetes.

Choice B reason: Managing blood pressure is important but not the primary goal in the context of newly diagnosed diabetes.

Choice C reason:

The correct answer is c) because achieving a hemoglobin A1C of less than 7% in 3 months is a measurable and relevant outcome for managing type 2 diabetes. It indicates good glycemic control and helps prevent complications.

Choice D reason: Encouraging physical activity is beneficial but is not a specific measurable outcome for diabetes management.

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The nurse is administering the second unit of whole blood to an older adult client who was admitted yesterday with gastrointestinal (GI) bleeding. Which parameters should the nurse monitor that indicate fluid overload?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?

Correct Answer is D

Explanation

The nurse is developing a plan of care for a client who reports blurred vision and who is newly diagnosed with type 2 diabetes mellitus (DM). Which outcome should the nurse include in the plan of care for this client?

Correct Answer is C

Explanation

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