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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:
Completing a neurological check is the correct action. The client’s sudden confusion and drowsiness could indicate a neurological issue, such as a stroke.
Choice B rationale:
Increasing the client’s fluid intake is not the first action to take. While dehydration can cause confusion, other causes need to be ruled out first.
Choice C rationale:
Administering the prescribed PRN antihypertensive medication is not the first action to take. The client’s blood pressure is not elevated, so this medication is not needed at this time.
Choice D rationale:
Holding the client’s evening dose of digoxin is not the first action to take. The client’s symptoms are not necessarily related to this medication.

A. Basal cell carcinoma. B. Actinic keratosis. C. Squamous cell carcinoma. D. Malignant melanoma.

Correct Answer is A

Explanation

Choice A rationale:
Basal cell carcinoma often appears as a raised, flesh-colored lesion with pearly, white borders. It is the most common type of skin cancer.
Choice B rationale:
Actinic keratosis is a precancerous skin condition that can lead to squamous cell carcinoma if left untreated. It typically presents as dry, scaly patches or spots.
Choice C rationale:
Squamous cell carcinoma often appears as a firm, red nodule or a flat lesion with a scaly, crusted surface.
Choice D rationale:
Malignant melanoma is a more serious type of skin cancer that can develop anywhere on the body. It often appears as a new, irregular, or changing mole.

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A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.).

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Naxlex Comprehensive Predictor Exams

A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 36.8° C (98.2° F). Which of the following actions should the nurse perform?

Correct Answer is A

Explanation

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly, white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer?

Correct Answer is A

Explanation

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A nurse is assessing a client who has fluid overload.

Which of the following findings should the nurse expect? (Select all that apply.).