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A nurse is caring for a heart failure client with a history of dietary non compliance. The nurse suspects the client has fluid volume overload. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY))

Increased blood pressure

increased heart rate

Increase hematocrit

Increased respiratory rate

Increased temperature

Answer and Explanation

Correct Answer : A,B,D

Rationale:

A. Fluid overload can lead to increased blood pressure due to the excess fluid circulating in the body.

B. Increased heart rate is a compensatory mechanism in response to fluid volume overload.

C. Increased hematocrit is not typically associated with fluid volume overload.

D. Increased respiratory rate is a compensatory mechanism in response to fluid volume overload.

E. Increased temperature is not typically associated with fluid volume overload.

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Correct Answer is ["A","B","C","E","F"]

Explanation

Rationale:

A. Unable to lie flat due to orthopnea is a sign of worsening heart failure.

B. Feeling fatigued is a general symptom of heart failure but can worsen as heart failure progresses.

C. Distended neck veins indicate increased central venous pressure, which is a sign of worsening right-sided heart failure.

D. Increased appetite is not typically associated with worsening heart failure.

E. Weight gain of 2 pounds in 24 hours indicates fluid retention and worsening heart failure.

F. Worsening lower extremity edema is a sign of worsening heart failure.

A. The client experiences sudden weakness of one arm and leg B. The client's ECG tracing shows irregular heart rate without P waves. C. The client's urine output is cloudy and odorous. D. The client has an aPTT of 80 seconds.

Correct Answer is A

Explanation

Rationale:

A. Sudden weakness of one arm and leg may indicate a stroke, which is a potential complication of atrial fibrillation.

B. An irregular heart rate without P waves is characteristic of atrial fibrillation and is expected.

C. Cloudy and odorous urine may indicate a urinary tract infection but is not the priority in this case.

D. An aPTT of 80 seconds is within the therapeutic range for heparin therapy.

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A nurse is caring for a heart failure client with a history of dietary non compliance. The nurse suspects the client has fluid volume overload. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY))

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with right sided heart failure. Which of the following symptoms should the nurse include in teaching the client about signs of worsening heart failure? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","C","E","F"]

Explanation

A nurse is caring for a client diagnosed with atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

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