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 A
Explanation
Choice A rationale:
Pulling the curtains around the client’s bed ensures privacy during the procedure.
Choice B rationale:
Asking family members to leave the room might be necessary, but it’s not the priority action.
Choice C rationale:
Using sterile drapes to cover the client is important for maintaining sterility, not privacy.
Choice D rationale:
Closing the door to the client’s room can provide privacy, but pulling the curtains around the bed is a more immediate action.
Correct Answer is D
Explanation
Choice A rationale:
While hypertension is a risk factor for stroke, it is modifiable through lifestyle changes and medication.
Choice B rationale:
Smoking is a modifiable risk factor for stroke. Quitting smoking can significantly reduce the risk of stroke.
Choice C rationale:
Obesity is a modifiable risk factor for stroke. Weight loss and maintaining a healthy weight can reduce the risk of stroke.
Choice D rationale:
Genetics is a nonmodifiable risk factor for stroke. Individuals with a family history of stroke are at a higher risk, and this cannot be changed.
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