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 B

Explanation

Choice A rationale:
Paralytic ileus can occur due to stress response but it’s not the immediate life-threatening issue.
Choice B rationale:
Airway obstruction is the immediate life-threatening issue due to swelling from burns in the head, neck, and chest area.
Choice C rationale:
Infection is a risk with burns but it’s not the immediate concern.
Choice D rationale:
Fluid imbalance is a concern due to loss from damaged skin but airway patency is the priority.

A. "A weight reduction program will make me hypoglycemic.”. B. "Insulin allows me to eat ice cream at bedtime.”. C. "I give the insulin injections in my abdominal area.”. D. "I am to take my blood sugar reading after meals.”.

Correct Answer is C

Explanation

Choice A rationale:
Weight reduction programs are generally beneficial for type 2 diabetes, not type 1.
Choice B rationale:
Insulin does not permit unrestricted dietary choices.
Choice C rationale:
Insulin injections are often given in the abdominal area due to its high vascularity, promoting faster absorption.
Choice D rationale:
Blood sugar readings are typically taken before meals to determine insulin dosage.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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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.).