Pharmacology Proctored ATI Practice Exam

What manifestations should a nurse monitor to prevent fluid volume overload in a client receiving RBC transfusion?

1. Increased heart rate

2. Dyspnea, jugular vein distention, confusion

3. Elevated body temperature

4. Decreased blood pressure

The correct answer is: Dyspnea, jugular vein distention, confusion

Monitoring for dyspnea, jugular vein distention, and confusion are important manifestations to watch for in a client receiving RBC transfusion to prevent fluid volume overload. These symptoms can indicate excessive fluid volume in the bloodstream, which can lead to complications such as heart failure and pulmonary edema. Increased heart rate (choice A) and elevated body temperature (choice C) are not typically associated with fluid volume overload in the context of RBC transfusion. Decreased blood pressure (choice D) is more commonly seen in hypovolemia rather than fluid volume overload.