The nurse is assessing a client diagnosed with fluid overload. The nurse should implement priority interventions for which of the following assessment findings? (Select all that apply.)

Increased temperature

Increase hematocrit

Blood pressure 180/100

Respiratory rate 32

Heart rate 120bpm

Answer and Explanation

Correct Answer : C,D

A. Increased temperature: Fluid overload typically doesn't cause an increased temperature. Infections or other inflammatory processes are more likely causes of elevated body temperature.

B. Increased hematocrit: Fluid overload usually results in dilution of blood components, leading to a decreased hematocrit (lower concentration of red blood cells in the blood). An increased hematocrit is not a typical finding in fluid overload.

C. Blood pressure 180/100: Elevated blood pressure can be associated with fluid overload, especially if the overload is chronic. This is a correct assessment finding that requires intervention and monitoring.

D. Respiratory rate 32: An increased respiratory rate can be a sign of respiratory distress, which may occur in severe cases of fluid overload, especially if it leads to pulmonary edema. This is a correct assessment finding that requires intervention and further evaluation.

E. Heart rate 120 bpm: An increased heart rate can be a compensatory mechanism in response to fluid overload, especially if the heart is trying to maintain cardiac output. However, this heart rate alone is not specific enough to confirm fluid overload. Other signs and symptoms, such as edema, increased blood pressure, and respiratory distress, are more indicative of fluid overload.

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Correct Answer is C

Explanation

A. Xerostomia: Xerostomia refers to dry mouth, which is caused by reduced saliva production. While it can be a symptom of various conditions, it is not directly associated with facial drooping after a stroke.

B. Epistaxis: Epistaxis is a medical term for a nosebleed. It occurs due to the rupture of small, delicate blood vessels within the nose. While it can happen independently of a stroke, it is not directly related to facial drooping caused by a stroke.

C. Dysphagia: Dysphagia refers to difficulty in swallowing, which can occur after a stroke due to muscle weakness, including the facial muscles. Facial drooping on one side can be indicative of stroke-related muscle weakness and can contribute to difficulties in swallowing.

D. Rhinorrhea: Rhinorrhea is the medical term for a runny nose, where the nasal cavity is filled with a significant amount of mucus. It is usually caused by various factors such as allergies, infections, or irritants. Rhinorrhea is not directly associated with facial drooping after a stroke.

A. When part of the lung is obstructed or collapsed B. When bulging of the intercostal spaces is present C. In an obese patient D. When accessory muscles are used to augment respiratory effort

Correct Answer is A

Explanation

A. When part of the lung is obstructed or collapsed: This statement is accurate. Unequal chest expansion can occur when part of the lung is obstructed or collapsed, preventing the affected area from expanding normally during inhalation.

B. When bulging of the intercostal spaces is present: This statement is not accurate. Unequal chest expansion typically refers to decreased expansion on one side, not bulging of intercostal spaces.

C. In an obese patient: This statement is not accurate. Obesity can affect breathing patterns and lung function, but it is not the primary cause of unequal chest expansion.

D. When accessory muscles are used to augment respiratory effort: This statement is not accurate. The use of accessory muscles to augment respiratory effort can be a sign of respiratory distress, but it doesn't directly cause unequal chest expansion. Unequal expansion is more indicative of specific lung conditions or issues with lung mechanics.

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The nurse is assessing a client diagnosed with fluid overload. The nurse should implement priority interventions for which of the following assessment findings? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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