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

Increased respiratory rate

Increase hematocrit

Increased blood pressure

Increased temperature

Increased Heart Rate

Answer and Explanation

Correct Answer : A,C,E

A.   Fluid overload can lead to pulmonary edema and difficulty breathing, resulting in an increased respiratory rate.
B.   Fluid overload typically leads to dilution of blood, which can result in a decreased hematocrit.
C.   Fluid overload can lead to increased blood volume and increased pressure on the blood vessel walls, resulting in increased blood pressure.
D.   Fluid overload is not typically associated with an increased body temperature.
E.   Fluid overload can lead to increased blood volume and increased pressure on the heart, resulting in an increased heart rate.

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Correct Answer is ["B","D","E","G"]

Explanation

A. Inserting a nasogastric (NG) tube is not a priority action in the initial management of sepsis.
B. Measuring lactate levels is a priority action in the initial management of sepsis. Elevated lactate levels indicate tissue hypoxia and are associated with increased mortality in septic patients.
C. Obtaining a wound culture is not a priority action in the initial management of sepsis.
D. Administering broad-spectrum antibiotics is a priority action in the initial management of sepsis. Prompt antibiotic therapy is associated with improved outcomes in septic patients.
E. Obtaining blood cultures is a priority action in the initial management of sepsis. Blood cultures help identify the causative organism and guide antibiotic therapy.
F. Type and cross-matching for packed RBCs is not a priority action in the initial management of sepsis.
G. Rapidly administering 30 mL/kg of normal saline is a priority action in the initial management of sepsis. This bolus of fluid helps restore tissue perfusion and hemodynamic stability.
H. Obtaining a urine specimen is not a priority action in the initial management of sepsis.

A. "I need to catch the bird that is flying in my room." B. "I feel like someone is watching me." C. "I have a difficult time remembering things." D. "I am sad no matter how well things are going."

Correct Answer is C

Explanation

A. This statement suggests a delusion or hallucination, which are common symptoms of some mental disorders, but it does not specifically suggest an inability to process new information.
B. This statement suggests paranoia, which is a common symptom of some mental disorders, but it does not specifically suggest an inability to process new information.
C. This statement suggests difficulty with memory, which is a cognitive function that is related to the ability to process new information.
D. This statement suggests a persistent negative mood, which is a symptom of some mental disorders, but it does not specifically suggest an inability to process new information.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for a 73-year-old client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications.

Correct Answer is ["B","D","E","G"]

Explanation

A nurse is caring for a client who has a mental disorder. Which of the following statements by the client suggests the inability to process new information?

Correct Answer is C

Explanation

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