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.

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Correct Answer is C

Explanation

Choice A rationale:
Trimming the nails at the lateral corners can lead to ingrown toenails, which can cause pain and infection.
Choice B rationale:
Cleaning under the nail with an orange stick can cause injury to the nail bed and lead to infection.
Choice C rationale:
Filing the nails in a rounded shape can prevent injury and is the recommended method for nail care.
Choice D rationale:
Pushing the cuticles back with a metal nail file can cause injury and infection.

A. Administer pain medication. B. Administer a tetanus booster. C. Clean and dress the wound. D. Administer IV fluids.

Correct Answer is D

Explanation

Choice A rationale:
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
Choice B rationale:
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice C rationale:
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice D rationale:
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.

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

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A nurse is assessing a client who has fluid overload.

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