A nurse is assessing a client who has fluid overload.
Which of the following findings should the nurse expect? (Select all that apply.).
Increased heart rate.
Increased respiratory rate.
Increased temperature.
Increased hematocrit.
Increased blood pressure.
Correct Answer : A,B,E
Choice A rationale:
Increased heart rate is a compensatory mechanism to maintain cardiac output in the presence of fluid overload.
Choice B rationale:
Increased respiratory rate may occur due to pulmonary congestion caused by fluid overload.
Choice C rationale:
Increased temperature is not typically associated with fluid overload.
Choice D rationale:
Increased hematocrit would indicate dehydration, not fluid overload.
Choice E rationale:
Increased blood pressure can occur due to increased blood volume in fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Urinary retention is not typically associated with menopause.
Choice B rationale:
Dryness with intercourse is a common symptom of menopause due to decreased estrogen levels.
Choice C rationale:
An elevation in body temperature above 37.8° C (100° F) is not typically associated with menopause.
Choice D rationale:
Decreased blood pressure is not typically associated with menopause.
Correct Answer is B
Explanation
The correct answer is choice B. Inject 20 units of air into the NPH insulin vial.
Choice A rationale:
Replacing the needle for withdrawal with a safety needle is an important step to ensure safety and prevent needle-stick injuries. However, this action is not the first step when mixing two types of insulin. The initial steps involve preparing the insulin vials by injecting air into them.
Choice B rationale:
Injecting 20 units of air into the NPH insulin vial is the correct first step. This is because NPH insulin is a suspension and needs to be mixed properly. Injecting air into the vial helps to equalize the pressure, making it easier to withdraw the correct amount of insulin later. This step is crucial to ensure accurate dosing and proper mixing of the insulin.
Choice C rationale:
Injecting 10 units of air into the regular insulin vial is also necessary, but it is not the first step. The correct sequence is to first inject air into the NPH insulin vial, then into the regular insulin vial. This order helps prevent contamination of the regular insulin with NPH insulin.
Choice D rationale:
Withdrawing 10 units of insulin from the regular insulin vial is an important step, but it should be done after injecting air into both vials. The correct sequence ensures that the insulin is mixed properly and that the doses are accurate.
By following these steps in the correct order, the nurse ensures that the insulin is mixed safely and effectively, minimizing the risk of errors and ensuring proper glycemic control for the patient.
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