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 A

Explanation

Choice A reason:

The correct answer is a) because visualizing the abdominal incision will help the nurse assess for wound dehiscence or evisceration, which requires immediate intervention.

Choice B reason: Notifying the healthcare provider is necessary but comes after assessing the wound.

Choice C reason: Obtaining sterile towels soaked in saline is important if dehiscence or evisceration is confirmed but is not the first action.

Choice D reason: Reassuring the client is important but does not address the immediate need to assess the wound.

A. Frequent use of chewable and liquid antacids for indigestion. B. Upper midabdominal pain described as gnawing and burning. C. Marked loss of weight and appetite over the last 3 or 4 months. D. Severe abdominal cramps and diarrhea after eating spicy foods.

Correct Answer is B

Explanation

Choice A reason: Frequent use of antacids may suggest gastrointestinal issues but is not specific to peptic ulcer disease.

Choice B reason:

The correct answer is b) because upper midabdominal pain described as gnawing and burning is a classic symptom of peptic ulcer disease.

Choice C reason: Marked loss of weight and appetite can be associated with many conditions and is not specific to peptic ulcer disease.

Choice D reason: Severe abdominal cramps and diarrhea after eating spicy foods are not typical symptoms of peptic ulcer disease.

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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?

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