Nokea
The nurse is monitoring the fluid status of a 63-year-old woman receiving IV fluids following surgery.
- A. Which symptoms suggest fluid volume overload in a 63-year-old woman receiving IV fluids post-surgery?
- B. Temperature 101°F (3°C), BP 96/60, pulse 96 and thready.
- C. Cool skin, respiratory crackles, pulse 86 and bounding.
- D. Complaints of a headache, abdominal pain, and lethargy.
- E. Urinary output 700 cc/24h, CVP of 5, and nystagmus.
Correct Answer: B
Rationale: Fluid volume overload is characterized by symptoms such as a bounding pulse, elevated blood pressure, respiratory crackles (due to pulmonary edema), and distended neck veins. Cool skin and respiratory crackles with a bounding pulse are indicative of this condition. The other options suggest dehydration, non-specific symptoms, or normal findings unrelated to fluid overload.
You may also like to solve these questions
A client experiencing alcohol withdrawal.
Which finding would indicate to the nurse that a client experiencing alcohol withdrawal is in need of more sedation to control the severity of withdrawal symptoms?
- A. Increasing lethargy.
- B. Uncoordinated motor movements.
- C. Elevated pulse rate.
- D. Improved orientation to time and place.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates to alcohol withdrawal. (1) would indicate a need for less sedation and a thorough physical assessment (2) suggests neurological trauma or damage (3) correct-pulse rate is a good indicator of client's progress through withdrawal, increasingly elevated pulse signals impending alcohol withdrawal delirium, requiring more sedation (4) suggests that the client is improving and will subsequently require less sedation
A client has a chest tube inserted for treatment of a hemothorax.
Which of the following findings would indicate to the nurse that there is a problem with the effective functioning of the chest tube?
- A. 15-cm of water is present in the suction control chamber.
- B. Constant bubbling is observed in the water seal chamber.
- C. 2-cm of water is present in the water seal chamber.
- D. Clots of blood are observed in the collection chamber.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) appropriate, regulates the amount of suction delivered to the patient (2) correct-would indicate an air leak, would not allow negative pressure to be reestablished and would hinder complete resolution of the pneumothorax (3) appropriate, provides for a water seal (4) would be an expected finding
The nurse has administered sublingual nitroglycerin (Nitrostat) to a client complaining of chest pain.
Which of the following observations is MOST important for the nurse to report to the next shift?
- A. The client indicates the need to use the bathroom.
- B. Blood pressure has decreased from 140/80 to 90/60.
- C. Respiratory rate has increased from 16 to 24.
- D. The client indicates that the chest pain has subsided.
Correct Answer: B
Rationale: Strategy: The topic of the question is unstated. Read answer choices for clues. (1) not a side effect of this medication (2) correct-hypotension is significant side effect of nitroglycerin; although effect may be transient, BP should be closely observed to ensure that it does not continue to decrease (3) not a side effect of this medication (4) an expected outcome
A female client is diagnosed with human papillomavirus (HPV).
Which of the following client statements, if made to the nurse, illustrates an understanding of the possible sequelae of this illness?
- A. I will need to take antibiotics for at least a week.'
- B. I will use only prescribed douches to avoid a recurrence.'
- C. I will return for a Pap smear in six months.'
- D. I will avoid using tampons for eight weeks.'
Correct Answer: C
Rationale: Strategy: Determine the 'hidden meaning' of the answer choices. (1) antibiotics are not used for viral infections (2) douches will not prevent recurrence (3) correct-several strains of the human papillomavirus (HPV) are associated with cervical cancer (4) tampons would not be a problem as in toxic shock syndrome
The client is admitted to the intensive care unit with severe chest pain. Which information provides the nurse with the most data that can be utilized in planning care?
- A. The blood pressure
- B. The vital signs
- C. The pulse oximeter
- D. The EEG
Correct Answer: B
Rationale: Vital signs include blood pressure, pulse, respirations, and temperature, providing the most comprehensive data for planning care in a client with severe chest pain. Blood pressure and pulse oximeter are included in vital signs, and EEG is irrelevant for chest pain.