A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?

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Question 1 of 5

A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?

Correct Answer: A

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 5

A 64-year-old male client is admitted to the hospital with benign prostatic hypertrophy (BPH). The client has a history of adult onset diabetes mellitus and hypertension. He is scheduled to undergo a resection of the prostate. The most serious symptom that may accompany BPH is:

Correct Answer: A

Rationale: Acute urinary retention is a symptom of BPH, is serious, and requires urgent medical attention. Hesitancy in starting urination is a symptom of BPH, but it is not serious or life-threatening. Increased frequency of urination is a symptom of BPH, but it is not serious or life-threatening. Decreased force of the urinary stream is due to an obstruction, but it is not serious or life-threatening.

Question 3 of 5

A 44-year-old female client had an emergency cholecystectomy three days ago for a ruptured gallbladder. The client has severe abdominal pain, abdominal rigidity, distension, increased temperature, tachycardia and an elevated white blood count (WBC). The client has probably developed:

Correct Answer: C

Rationale: Assessment findings of gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity, which causes infection and irritation. Assessment findings of a pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing, often accompanied by blood-tinged sputum.

Question 4 of 5

A male client has returned to the Unit following a left femoral popliteal bypass graft. Six hours later, the client's dorsalis pedis pulse cannot be palpated and his foot is cool and dusky. The nurse should:

Correct Answer: B

Rationale: The client is losing the blood supply to his left foot. Continuing to monitor will not restore the blood supply to the foot. The physician should be notified immediately because the client is losing the blood supply to his left foot and is in danger of losing his foot and/or his leg. It is the responsibility of the nurse caring for the client to notify the physician, not the head nurse. This would be giving the client false assurances, which is unethical, demeaning, and could have legal consequences.

Question 5 of 5

A female postoperative client has returned to the Unit following a pneumonectomy. In assessing the client's incision, twenty-four hours postoperatively, the nurse notices fresh blood on the dressing. The nurse should first:

Correct Answer: C

Rationale: The dressing should not be reinforced without notifying the physician. The physician may decide to reinforce the dressing after assessing the amount of bleeding. Blood on the dressing is unusual, which should alert the nurse to do more than monitor the dressing. The physician should be notified immediately. If the bleeding persists, the client may need to return to surgery. The time and amount of blood needs to be recorded, but only after the physician is notified.

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