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 ["B","D","E","G"]

Explanation

A. Inserting a nasogastric (NG) tube is not a priority action in the initial management of sepsis.
B. Measuring lactate levels is a priority action in the initial management of sepsis. Elevated lactate levels indicate tissue hypoxia and are associated with increased mortality in septic patients.
C. Obtaining a wound culture is not a priority action in the initial management of sepsis.
D. Administering broad-spectrum antibiotics is a priority action in the initial management of sepsis. Prompt antibiotic therapy is associated with improved outcomes in septic patients.
E. Obtaining blood cultures is a priority action in the initial management of sepsis. Blood cultures help identify the causative organism and guide antibiotic therapy.
F. Type and cross-matching for packed RBCs is not a priority action in the initial management of sepsis.
G. Rapidly administering 30 mL/kg of normal saline is a priority action in the initial management of sepsis. This bolus of fluid helps restore tissue perfusion and hemodynamic stability.
H. Obtaining a urine specimen is not a priority action in the initial management of sepsis.

A. Lower than normal expected reference range of body weight B. Amenorrhea C. Hyperkalemia D. Dental decay

Correct Answer is D

Explanation

A. Clients with bulimia nervosa may have a normal or above-normal body weight, as bulimia nervosa is characterized by episodes of binge eating followed by compensatory behaviors such as vomiting or excessive exercise.
B. Amenorrhea, or the absence of menstruation, is more commonly associated with anorexia nervosa rather than bulimia nervosa.
C. Hyperkalemia, or high levels of potassium in the blood, is not a common finding in clients with bulimia nervosa.
D. Frequent self-induced vomiting can lead to dental erosion and decay due to exposure of the teeth to stomach acid.

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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 caring for a 73-year-old client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.

Correct Answer is ["B","D","E","G"]

Explanation

A nurse is caring for a female client who has bulimia nervosa and reports frequent self-induced vomiting. Which of the following findings should the nurse expect?

Correct Answer is D

Explanation

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