A nurse is assessing a client with fluid volume overload. Which of the following findings should the nurse expect?
Increased temperature
Increased blood pressure
Bradycardia
Increased hematocrit
The Correct Answer is B
Choice A reason:
Increased temperature is not a typical finding associated with fluid volume overload. Fluid volume overload affects the circulatory and respiratory systems primarily, and while fever can indicate infection or inflammation, it is not a direct consequence of fluid volume excess.
Choice B reason:
Increased blood pressure is a common finding in fluid volume overload due to the increased volume of blood in the circulatory system. This excess volume can lead to hypertension as the heart works harder to pump the additional fluid, making this a key indicator of fluid volume overload.
Choice C reason:
Bradycardia, or a slow heart rate, is not typically associated with fluid volume overload. In fact, fluid overload often leads to tachycardia as the heart tries to compensate for the increased volume. Bradycardia could indicate other cardiac conditions but is not a sign of fluid volume excess.
Choice D reason:
Increased hematocrit is not expected in fluid volume overload. Hematocrit measures the proportion of red blood cells in the blood, and with fluid overload, this proportion is usually diluted, leading to a lower hematocrit level rather than an increased one.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
A trochanter roll is used to prevent external rotation of the hips in immobilized clients. While important for hip alignment, it does not address the prevention of plantar flexion contractures.
Choice B reason:
A sheepskin heel pad is used to protect the heels and prevent pressure sores, but it does not specifically prevent plantar flexion contractures. It is more for skin protection rather than positioning of the foot.
Choice C reason:
A footboard is designed to keep the feet in a dorsiflexed position, preventing plantar flexion contractures. It ensures proper alignment of the ankles and feet, which helps maintain flexibility and prevent the tightening of the Achilles tendon and calf muscles.
Choice D reason:
An abduction pillow is used to maintain proper hip alignment, especially after hip surgery. It does not serve to prevent plantar flexion contractures, which affect the ankles and feet rather than the hips.
Correct Answer is D
Explanation
Choice A reason: The Rinne test does not involve wearing earphones. This statement may indicate a misunderstanding or confusion with other hearing tests that use earphones to deliver sounds. The Rinne test specifically uses a tuning fork.
Choice B reason: The Rinne test does not involve inserting any probes into the ear. This statement is incorrect and indicates the client does not fully understand the procedure, which involves comparing air and bone conduction of sound.
Choice C reason: Small electrodes placed on the scalp are used in other diagnostic tests, such as EEGs (electroencephalograms), to measure electrical activity in the brain. This is not relevant to the Rinne test, which assesses hearing using a tuning fork.
Choice D reason: This is the correct answer. In the Rinne test, a tuning fork is struck and then placed on the mastoid process (behind the ear) and near the ear canal to compare bone and air conduction of sound. This statement indicates the client understands the test procedure.
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