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. Anorexia is a common symptom of infective endocarditis but is not typically the priority assessment finding.
B. Fever is a hallmark sign of infective endocarditis and should be monitored closely.
C. Dyspnea is a common symptom of infective endocarditis but is not typically the priority assessment finding.
D. Malaise is a common symptom of infective endocarditis but is not typically the priority assessment finding.
Correct Answer is D
Explanation
Rationale:
A. Synchronized cardioversion is not appropriate for pulseless ventricular tachycardia.
B. A repeat ECG is not necessary for pulseless ventricular tachycardia.
C. Assessment of blood pressure is not the priority in pulseless ventricular tachycardia.
D. Immediate defibrillation is the priority in pulseless ventricular tachycardia to restore a perfusing rhythm.
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