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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C,A,E,B,D

Explanation

Here's the correct order of actions for managing an IV infiltration: C. Stop the infusion. (This is the priority action to prevent further infiltration.) A. Remove the IV catheter. (Once the infusion is stopped, the source of the infiltration needs to be removed.) E. Elevate the extremity. (This helps reduce swelling.) B. Apply warm or cold compresses. (This helps reduce discomfort and swelling. Warm compresses are generally used for non-vesicant solutions, while cold compresses are used for vesicant solutions, or as ordered. The type of fluid infiltrated is important to know.) D. Apply a sterile dressing. (This protects the insertion site and prevents infection.)

A. The burned area is pink in color with blisters present. B. The burned area is yellow in color with severe edema. C. The burned area is black in color and pain is absent. D. The burned area is red in color with eschar present.

Correct Answer is B

Explanation

Choice A rationale:
A pink color with blisters present is indicative of a superficial partial-thickness burn, not a deep partial-thickness burn.
Choice B rationale:
A yellow color with severe edema is indicative of a deep partial-thickness burn. This type of burn involves the entire dermis and damage to nerve endings, blood vessels, and sweat glands.
Choice C rationale:
A black color and absence of pain is indicative of a full-thickness burn, not a deep partial-thickness burn.
Choice D rationale:
A red color with eschar present is indicative of a full-thickness burn, not a deep partial-thickness burn.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client and identifies an infiltration at the IV catheter site. Identify the order the nurse should perform the following actions. (Move the steps into the box on the right, placing them in the selected order of performance. All steps must be used.).

Correct Answer is C,A,E,B,D

Explanation

A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?

A nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. The nurse should expect the client to report:

A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

A nurse is caring for a client who has peripheral vascular disease and reports difficulty sleeping because of cold feet. Which of the following nursing actions should the nurse take to promote the client's comfort?

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.).

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply.).

A nurse is assessing a client who has fluid overload.

Which of the following findings should the nurse expect? (Select all that apply.).