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

Increased respiratory rate

Increase hematocrit

Increased blood pressure

Increased temperature

Increased Heart Rate

Answer and Explanation

Correct Answer : A,C,E

A.   Fluid overload can lead to pulmonary edema and difficulty breathing, resulting in an increased respiratory rate.
B.   Fluid overload typically leads to dilution of blood, which can result in a decreased hematocrit.
C.   Fluid overload can lead to increased blood volume and increased pressure on the blood vessel walls, resulting in increased blood pressure.
D.   Fluid overload is not typically associated with an increased body temperature.
E.   Fluid overload can lead to increased blood volume and increased pressure on the heart, resulting in an increased heart rate.

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Correct Answer is C,A,D,B,E

Explanation

The correct order is C,A,D,B,E.

C. Open the airway using a jaw-thrust maneuver.

This is the first priority since maintaining a clear airway is critical for the client’s survival.

A. Determine effectiveness of ventilatory efforts.

After ensuring the airway is open, assess the client’s breathing and whether they are ventilating effectively.

D. Perform a Glasgow Coma Scale assessment.

This step evaluates the client’s neurological status to determine their level of consciousness and identify any brain injuries.

B. Remove clothing for a thorough assessment.

To expose the client for a comprehensive physical examination and assess any injuries.

E. Control any external bleeding.

As part of circulation management, identify and stop any significant bleeding to prevent shock. This step addresses the "C" in ABCDE.

A. Aphasia B. Inability to recognize his family members C. Right hemiparesis D. Difficulty reading

Correct Answer is B

Explanation

A. Aphasia, or difficulty with language comprehension and expression, is more commonly associated with left hemisphere strokes.
B. Inability to recognize family members is a possible manifestation of right hemisphere stroke, particularly if the stroke affects the right parietal lobe. This condition is called prosopagnosia.
C. Right hemiparesis, or weakness on the right side of the body, is a possible manifestation of left hemisphere stroke, not right hemisphere stroke.
D. Difficulty reading is more commonly associated with left hemisphere strokes, which affect language centers involved in reading.

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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 is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is C,A,D,B,E

Explanation

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