A nurse is assessing a client who has fluid overload.
Which of the following findings should the nurse expect? (Select all that apply.).
Increased heart rate.
Increased respiratory rate.
Increased temperature.
Increased hematocrit.
Increased blood pressure.
Correct Answer : A,B,E
Choice A rationale:
Increased heart rate is a compensatory mechanism to maintain cardiac output in the presence of fluid overload.
Choice B rationale:
Increased respiratory rate may occur due to pulmonary congestion caused by fluid overload.
Choice C rationale:
Increased temperature is not typically associated with fluid overload.
Choice D rationale:
Increased hematocrit would indicate dehydration, not fluid overload.
Choice E rationale:
Increased blood pressure can occur due to increased blood volume in fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["D","E"]
Explanation
Choice A rationale:
Polydipsia, or excessive thirst, is a symptom of hyperglycemia, not hypoglycemia.
Choice B rationale:
Polyuria, or frequent urination, is also a symptom of hyperglycemia, not hypoglycemia.
Choice C rationale:
Blurred vision can be a symptom of both hyperglycemia and hypoglycemia, but it’s more commonly associated with hyperglycemia.
Choice D rationale:
Moist, clammy skin is a symptom of hypoglycemia.
Choice E rationale:
Tachycardia, or a fast heartbeat, is a symptom of hypoglycemia.
Correct Answer is B
Explanation
Choice A rationale:
Turning the client’s head to the side is important to prevent aspiration, but it should be done after documenting the time the seizure began.
Choice B rationale:
The first action when a client begins having a tonic-clonic seizure is to document the time the seizure began. This helps in determining the duration of the seizure, which is critical information for the healthcare team.
Choice C rationale:
Loosening the clothing around the client’s waist is important for the client’s comfort and safety during a seizure, but it should be done after documenting the time the seizure began.
Choice D rationale:
Checking the client’s motor strength is not the first action to take when a client begins having a tonic-clonic seizure.
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