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 B

Explanation

Choice A rationale:
Paralytic ileus can occur due to stress response but it’s not the immediate life-threatening issue.
Choice B rationale:
Airway obstruction is the immediate life-threatening issue due to swelling from burns in the head, neck, and chest area.
Choice C rationale:
Infection is a risk with burns but it’s not the immediate concern.
Choice D rationale:
Fluid imbalance is a concern due to loss from damaged skin but airway patency is the priority.

A. "Place your legs in a dependent position while in bed.”. B. "Remain on bed rest.”. C. "Use elastic stockings.”. D. "Apply ice packs to your legs.”.

Correct Answer is C

Explanation

Choice A rationale:
Placing the legs in a dependent position can increase venous pressure and exacerbate venous insufficiency.
Choice B rationale:
Bed rest can lead to venous stasis and worsen venous insufficiency.
Choice C rationale:
Using elastic stockings can help improve venous return and reduce symptoms of venous insufficiency.
Choice D rationale:
Applying ice packs can constrict blood vessels and reduce blood flow, which is not recommended for venous insufficiency.

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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

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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.).