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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Looking for P waves is important for assessing atrial activity, but it does not directly calculate heart rate.
B. Counting how many QRS complexes occur in a 6-second strip and multiplying by 10 is a quick and accurate way to calculate heart rate.
C. Reading the monitor or ECG interpretation provides information about the rhythm and morphology of the heart, but it does not directly calculate heart rate.
D. Measuring T waves is important for assessing cardiac repolarization, but it does not directly calculate heart rate.
Correct Answer is ["A","B","D"]
Explanation
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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