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

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A reason:

Ferrous sulfate is often taken for longer than 14 days, depending on the severity of the iron deficiency. The duration of treatment is typically based on the individual's response and their laboratory values, rather than a fixed short-term period.

Choice B reason:

Taking ferrous sulfate with a glass of milk is not recommended as calcium in milk can inhibit the absorption of iron. Instead, it should be taken with water or a beverage high in vitamin C, which enhances iron absorption.

Choice C reason:

Foods high in vitamin C, such as oranges, strawberries, and bell peppers, will promote the absorption of iron. Vitamin C converts iron into a form that is more easily absorbed by the body, making this advice essential for maximizing the effectiveness of the iron supplement.

Choice D reason:

Stools are often dark, tarry, or greenish in color when taking iron supplements, not dark red. This coloration is due to the unabsorbed iron and is a normal side effect of ferrous sulfate, not indicative of gastrointestinal bleeding.

A. Respiratory rate B. Urine output C. Bowel sounds D. Pupil reaction

Correct Answer is A

Explanation

Choice A reason:

Respiratory rate is the priority assessment before administering morphine because morphine can cause respiratory depression, a serious side effect. Monitoring the client's respiratory status ensures that the morphine does not significantly depress their breathing, which could lead to life-threatening hypoventilation.

Choice B reason:

While monitoring urine output is important for overall patient care, it is not the immediate priority before morphine administration. Morphine's primary concern is its impact on the respiratory system rather than renal function.

Choice C reason:

Assessing bowel sounds is relevant for managing potential constipation due to morphine use but is not the immediate priority before administration. Respiratory rate takes precedence because of the risk of respiratory depression.

Choice D reason:

Pupil reaction can indicate narcotic effect and neurological status but is not the immediate priority over respiratory rate. Ensuring the client’s respiratory status is stable is the most crucial step before administering morphine.

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A nurse is assessing a client with fluid volume overload. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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