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 A

Explanation

Choice A reason:

Renal failure is a contraindication for thiazide diuretics because these medications require adequate kidney function to be effective. In renal failure, the kidneys are not able to filter and excrete the medication properly, which can lead to toxic accumulation and adverse effects.

Choice B reason:

Hypertension is an indication for thiazide diuretics, not a contraindication. These medications are commonly used to help control high blood pressure by reducing fluid volume in the body.

Choice C reason:

Heart failure can be managed with thiazide diuretics as they help reduce fluid overload and improve symptoms. It is not a contraindication for this class of medication.

Choice D reason:

Idiopathic hypercalciuria, a condition of elevated calcium levels in the urine, can actually be managed with thiazide diuretics. These medications help reduce the amount of calcium excreted in the urine, making them beneficial rather than contraindicated.

A. Reposition the client every 2 hours. B. Massage the skin over the client's bony prominences. C. Position the client in high Fowler's. D. Apply cornstarch to keep sensitive skin areas dry.

Correct Answer is A

Explanation

Choice A reason:

Repositioning the client every 2 hours is a standard preventive measure to reduce the risk of pressure ulcers. Frequent repositioning helps alleviate pressure on vulnerable areas, improving circulation and preventing skin breakdown. This intervention is widely recommended to maintain skin integrity in at-risk clients.

Choice B reason:

Massaging the skin over bony prominences can cause tissue damage and increase the risk of pressure ulcers. Instead of promoting circulation, it can exacerbate skin breakdown and should be avoided as a preventive measure.

Choice C reason:

Positioning the client in high Fowler's is not specifically related to preventing pressure ulcers. High Fowler's position can help with respiratory issues but does not address pressure redistribution needed to prevent skin breakdown in vulnerable areas.

Choice D reason:

Applying cornstarch to keep sensitive skin areas dry is not an evidence-based intervention for pressure ulcer prevention. Cornstarch can create friction and irritation, potentially worsening skin integrity rather than preserving it.

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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 client recently diagnosed with hypertension is prescribed a thiazide diuretic. Which condition below would be a contraindication associated with thiazide diuretics?

Correct Answer is A

Explanation

A nurse is planning care for an older adult client at risk for developing pressure ulcers. Which intervention is appropriate to maintain skin integrity?

Correct Answer is A

Explanation

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