Nokea
During the assessment of a client receiving packed RBCs, which finding indicates fluid overload?
- A. Low back pain.
- B. Dyspnea.
- C. Hypotension.
- D. Thready pulse.
Correct Answer: B
Rationale: Dyspnea is a key finding indicating fluid overload in a client receiving packed RBCs. Fluid overload can lead to pulmonary edema, causing difficulty breathing or shortness of breath (dyspnea). Low back pain is not typically associated with fluid overload but can be more related to musculoskeletal issues. Hypotension and thready pulse are more indicative of hypovolemia (low fluid volume), not fluid overload.
You may also like to solve these questions
A client who wears glasses is under the care of a nurse. Which of the following actions should the nurse take?
- A. Store the glasses in a labeled case.
- B. Clean the glasses with hot water
- C. Clean the glasses with a paper towel.
- D. Store the glasses on the bedside table.
Correct Answer: A
Rationale: It is essential for the nurse to store the client's glasses in a labeled case to ensure they are kept safe and protected from damage. Storing them in a case helps prevent scratches, breakage, or misplacement. This practice promotes proper eyewear hygiene and ensures the client has their glasses readily available when needed. Cleaning the glasses with hot water or a paper towel can potentially damage the lenses or frames. Storing the glasses on the bedside table increases the risk of misplacement or damage.
A healthcare provider is performing a gastric lavage for a client who has upper gastrointestinal bleeding. Which of the following actions should the healthcare provider take?
- A. Instill 500 ml of solution through the NG tube.
- B. Insert a large-bore NG tube.
- C. Use a cold irrigation solution.
- D. Instruct the client to lie on their right side.
Correct Answer: B
Rationale: During a gastric lavage procedure for upper gastrointestinal bleeding, inserting a large-bore NG tube is essential to effectively remove gastric contents and blood. This tube allows for efficient irrigation and suction, aiding in the removal of harmful substances from the stomach. Instilling a large volume of solution or using a cold irrigation solution can lead to complications such as fluid overload or hypothermia. Instructing the client to lie on their right side is not directly related to the gastric lavage procedure.
Which of the following conditions in the client's history is a contraindication to the use of oral contraceptives?
- A. Hyperthyroidism.
- B. Thrombophlebitis.
- C. Diverticulosis.
- D. Hypocalcemia.
Correct Answer: B
Rationale: Thrombophlebitis, which is inflammation of a vein with the formation of a clot, is a contraindication to the use of oral contraceptives due to an increased risk of thromboembolism. Clients with a history of thrombophlebitis or thromboembolic disorders should avoid oral contraceptives to prevent further complications like deep vein thrombosis or pulmonary embolism.
A healthcare professional in an emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the healthcare professional take first?
- A. Obtain a baseline ECG.
- B. Obtain a blood specimen for ABG analysis.
- C. Insert an 18-gauge IV catheter.
- D. Administer 100% humidified oxygen.
Correct Answer: D
Rationale: In a client experiencing drooling and hoarseness following a burn injury, airway compromise is a critical concern. Administering 100% humidified oxygen is the priority to ensure adequate oxygenation. This intervention takes precedence over obtaining baseline ECG, obtaining blood specimens, or inserting an IV catheter, as airway management and oxygenation are fundamental in the initial assessment and management of a client with potential airway compromise.
A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?
- A. Administer the feeding over 30 minutes
- B. Place the child in a supine position after the feeding
- C. Change the feeding bag and tubing every 3 days
- D. Warm the formula in a warm water bath before administration
Correct Answer: B
Rationale: Administering the feeding over 30 minutes helps prevent complications such as aspiration. Placing the child in an upright position after the feeding is recommended to reduce the risk of aspiration. It is essential to change the feeding bag and tubing every 3 days to maintain asepsis and prevent infections. Warming the formula in a warm water bath is the correct method as using a microwave can create hot spots that may burn the child's mouth or throat.