A nurse is collecting data on a client who has circulatory overload. Which of the following findings should the nurse expect?
Tachycardia
Weight loss
Hypotension
Diaphoresis
The Correct Answer is A
Choice A reason: Tachycardia is a sign of circulatory overload. Circulatory overload is a condition where the blood volume or rate of infusion is too high for the client's cardiovascular system. This causes the heart to beat faster and harder to pump the excess fluid, resulting in a high heart rate, or tachycardia.
Choice B reason: Weight loss is not a sign of circulatory overload. Weight loss is a condition where the body loses more calories than it consumes, resulting in a decrease in body mass. Weight loss can be caused by various factors, such as diet, exercise, illness, or medication. Weight gain, not weight loss, is a sign of circulatory overload, as the excess fluid accumulates in the body.
Choice C reason: Hypotension is not a sign of circulatory overload. Hypotension is a condition where the blood pressure is too low, which can impair the blood flow to the vital organs. Hypotension can be caused by various factors, such as dehydration, bleeding, shock, or medication. Hypertension, not hypotension, is a sign of circulatory overload, as the excess fluid increases the pressure in the blood vessels.
Choice D reason: Diaphoresis is not a sign of circulatory overload. Diaphoresis is a condition where the body sweats excessively, which can help to regulate the body temperature and eliminate toxins. Diaphoresis can be caused by various factors, such as fever, anxiety, exercise, or medication. Edema, not diaphoresis, is a sign of circulatory overload, as the excess fluid leaks into the interstitial spaces and causes swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Caffeinated beverages can cause diarrhea by stimulating the intestinal motility and increasing the fluid loss. They can also irritate the lining of the stomach and intestines.
Choice B reason: Low-fiber cereal is not likely to cause diarrhea. Fiber helps to bulk up the stool and regulate the bowel movements. Low-fiber foods are often recommended for clients with diarrhea to reduce intestinal activity.
Choice C reason: White rice is not likely to cause diarrhea. It is a bland and starchy food that can help to bind the stool and reduce fluid loss. White rice is often part of the BRAT diet (bananas, rice, applesauce, toast) that is suggested for clients with diarrhea.
Choice D reason: Ripe bananas are not likely to cause diarrhea. They are rich in potassium, which can help to replenish the electrolytes lost due to diarrhea. They also contain pectin, a soluble fiber that can help to firm up the stool.
Correct Answer is A
Explanation
Choice A reason: Donning sterile gloves is an essential step to prevent contamination and infection during the insertion of an indwelling urinary catheter. The nurse should also use aseptic technique and a sterile catheter kit.
Choice B reason: Applying an oil-based lubricant to the indwelling urinary catheter is not recommended, as it can damage the latex material and increase the risk of catheter-associated urinary tract infection (CAUTI). The nurse should use a water-soluble lubricant instead.
Choice C reason: Testing the balloon on the indwelling urinary catheter before insertion is a good practice, as it ensures that the balloon is functioning properly and does not leak or burst. The nurse should inflate and deflate the balloon with sterile water or saline using a syringe.
Choice D reason: Using one cotton swab to clean the client's urinary meatus is not sufficient, as it may not remove all the bacteria and debris. The nurse should use at least three cotton swabs and clean the meatus from front to back in a circular motion. The nurse should also use an antiseptic solution such as chlorhexidine or povidone-iodine.
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