Page 2564 - Saunders Comprehensive Review For NCLEX-RN

2. Hypoactive bowel sounds
3. Temperature of 102° F (38.9° C)

4. Heart rate of 96 beats per minute

5. Mean arterial pressure 65 mm Hg

6. Systolic blood pressure 110 mm Hg

Answers

856. Answer: 1

Rationale: The client’s symptoms are compatible with circulatory overload. This
may be verified by noting that 600 mL has infused in the course of 45 minutes. The
first action of the nurse is to slow the infusion. Other actions may follow in rapid
sequence. The nurse may elevate the head of the bed to aid the client’s breathing, if
necessary. The nurse also notifies the PHCP. The IV catheter is not removed; it may
be needed for the administration of medications to resolve the complication.
Test-Taking Strategy: Note the strategic word, first. This tells you that more than 1
or all of the options are likely to be correct actions and that the nurse needs to
prioritize them according to a time sequence. You must be able to recognize the signs
of circulatory overload. From this point, select the option that provides the
intervention specific to circulatory overload.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Intravenous Therapy
Health Problem: N/A
Priority Concepts: Fluid and Electrolytes; Perfusion
Reference: Ignatavicius, Workman, Rebar (2018), p. 219.

857. Answer: 4

Rationale: If the client has a temperature higher than 100° F (37.8° C), the unit of
blood should not be hung until the primary PHCP is notified and has the
opportunity to give further prescriptions. The PHCP likely will prescribe that the
blood be administered regardless of the temperature, or may instruct the nurse to
administer prescribed acetaminophen and wait until the temperature has decreased
before administration, but the decision is not within the nurse’s scope of practice to
make. The nurse needs a PHCP’s prescription to administer medications to the
client.
Test-Taking Strategy: Eliminate all options that indicate to begin the transfusion,
noting that they are comparable or alike. In addition, the options including
antihistamine and acetaminophen indicate administering medication to the client,
which is not done without a PHCP’s prescription.

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