A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?

Diaphoresis

Weight loss

Hypotension

Tachycardia

Answer and Explanation

The Correct Answer is D

A) Diaphoresis:
While diaphoresis (excessive sweating) may occur with some cardiac or respiratory conditions, it is not a primary or expected sign of circulatory overload. Circulatory overload generally involves fluid accumulation in the body, and symptoms are more likely related to fluid retention and increased workload on the heart rather than sweating.

B) Weight loss:
Weight loss is not typically associated with circulatory overload. In fact, one of the hallmark signs of circulatory overload is weight gain due to fluid retention. The body retains excess fluid in the vascular system, leading to an increase in weight rather than weight loss.

C) Hypotension:
Hypotension (low blood pressure) is generally not associated with circulatory overload. Circulatory overload typically results in elevated blood pressure due to the increased volume of circulating fluid. In some cases, if the heart is unable to handle the increased volume, symptoms like pulmonary edema or shortness of breath can occur, but hypotension is more commonly seen in conditions like shock or severe fluid loss.

D) Tachycardia:
Tachycardia (an elevated heart rate) is a common finding in circulatory overload. When there is an excess of fluid in the body, the heart has to work harder to pump the additional volume of blood, leading to an increased heart rate. This is a compensatory response to the increased workload on the heart. It is also a sign that the body is attempting to maintain adequate tissue perfusion despite the excess fluid volume.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A) Teach the use of an incentive spirometer to a postoperative client:
Teaching a patient how to use an incentive spirometer involves assessment, education, and clinical judgment. This task requires the nurse's expertise to ensure that the patient understands how to use the device correctly and to assess for any potential complications, such as inadequate lung expansion.

B) Irrigate and perform a dressing change for a client who has a pressure injury wound:
Irrigating and changing the dressing of a pressure injury involves clinical judgment, the need for sterile technique, and the assessment of the wound. These tasks should be performed by a registered nurse (RN), who can assess the condition of the wound, evaluate for signs of infection, and make decisions regarding further care.

C) Administer oral PRN pain medication to a client who has arthritis:
Administering PRN pain medication requires assessment of the patient's pain level, consideration of the medication’s effects, and clinical judgment regarding the appropriateness of the medication. This is a nursing responsibility because it involves both medication management and the evaluation of therapeutic effects.

D) Obtain a daily weight on a client who has heart failure:
Obtaining a daily weight is a task that can be safely delegated to an assistive personnel (AP). Weight is an important measurement for monitoring fluid status, especially in clients with heart failure. The AP can accurately weigh the client, ensuring that the same scale and conditions (such as time of day, after the patient has voided) are followed each time.

Correct Answer is ["1"]

Explanation

Given:

Total daily dose of clonazepam: 1.5 mg

Frequency: Every 8 hours (3 doses per day)

Tablet strength: 0.5 mg

Step 1: Calculate the dose per administration:

Dose per administration = Total daily dose / Number of doses per day

Dose per administration = 1.5 mg / 3 doses

Dose per administration = 0.5 mg

Step 2: Determine the number of tablets per dose:

Number of tablets per dose = Dose per administration / Tablet strength

Number of tablets per dose = 0.5 mg / 0.5 mg/tablet

Number of tablets per dose = 1 tablet

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A nurse is assessing a client who has circulatory overload. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

Correct Answer is D

Explanation

Correct Answer is ["1"]

Explanation

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