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 A

Explanation

A. This is important information to include, as schizophrenia is a chronic condition that often requires ongoing support and resources.
B. Schizophrenia is typically diagnosed in late adolescence or early adulthood, not after 40 years of age.
C. Co-occurring mental health conditions, such as depression or anxiety, are common in individuals with schizophrenia.
D. While individuals with schizophrenia may have a reduced life expectancy, it is not typically as low as 50.2 years of age.

A. Determine effectiveness of ventilator efforts. B. Remove clothing for a thorough assessment. C. Open the airway using a jaw-thrust maneuver. D. Perform a Glasgow Coma Scale assessment. E. Control any external bleeding.

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

Explanation

The correct order is C,A,D,B,E.

C. Open the airway using a jaw-thrust maneuver.

This is the first priority since maintaining a clear airway is critical for the client’s survival.

A. Determine effectiveness of ventilatory efforts.

After ensuring the airway is open, assess the client’s breathing and whether they are ventilating effectively.

D. Perform a Glasgow Coma Scale assessment.

This step evaluates the client’s neurological status to determine their level of consciousness and identify any brain injuries.

B. Remove clothing for a thorough assessment.

To expose the client for a comprehensive physical examination and assess any injuries.

E. Control any external bleeding.

As part of circulation management, identify and stop any significant bleeding to prevent shock. This step addresses the "C" in ABCDE.

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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

A nurse is teaching a client who has been newly diagnosed with schizophrenia. Which of the following information should the nurse include?

Correct Answer is A

Explanation

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

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

Explanation

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