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 D

Explanation

Choice A reason:

Proceeding to measure the oral temperature immediately after the client has consumed ice chips is incorrect. The cold substance can lower the temperature reading, leading to inaccurate results. The oral temperature measurement would not reflect the client's true body temperature.

Choice B reason:

Documenting that the temperature was not measured is not a practical approach to this situation. While it records the inability to take a measurement, it does not address the need to obtain an accurate temperature reading after an appropriate waiting period.

Choice C reason:

Providing warm water and then measuring the temperature after 5 minutes is not advisable. This method can cause a rebound effect, where the warm water temporarily raises the oral temperature, again leading to an inaccurate reading. It also does not provide a sufficient waiting period for the mouth to return to its baseline temperature.

Choice D reason:

Waiting 30 minutes before remeasuring the oral temperature is the best practice. This period allows the oral cavity to return to its normal temperature, ensuring that the reading is accurate and reflective of the client's true body temperature. It avoids the influence of recent ingestion of cold substances.

A. A diuretic medication B. An oral anticoagulant medication C. A beta blocker medication D. An antihyperuricemic medication

Correct Answer is B

Explanation

Choice A reason:

A diuretic medication is generally used to remove excess fluid from the body and treat conditions such as hypertension and heart failure. While it can be part of the management plan for atrial fibrillation if there is fluid overload, it is not specifically used to prevent thromboembolic events like TIA, which are a major concern in atrial fibrillation patients.

Choice B reason:

An oral anticoagulant medication is the most appropriate choice for a patient with atrial fibrillation who has experienced a TIA. Anticoagulants, such as warfarin or newer direct oral anticoagulants (DOACs), are used to prevent blood clots from forming and reduce the risk of stroke and other thromboembolic events. This choice directly addresses the primary goal of reducing the risk of future TIAs or strokes in patients with atrial fibrillation.

Choice C reason:

A beta blocker medication can be useful in managing atrial fibrillation by controlling the heart rate and reducing the risk of symptomatic episodes. However, beta blockers do not address the risk of thromboembolism, which is critical in the context of a patient with a history of TIA. Thus, while beneficial for rate control, they do not serve the primary purpose of preventing strokes in this scenario.

Choice D reason:

An antihyperuricemic medication is used to lower uric acid levels and treat conditions like gout. It is not relevant to the management of atrial fibrillation or the prevention of thromboembolic events. Including this option does not align with the clinical needs of a patient with atrial fibrillation and a history of TIA.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is measuring a client's oral temperature. The client informs the nurse that he has just eaten some ice chips. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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