A nurse is assessing a client who is having fluid volume overload. Which finding should the nurse expect for this client?
Edema
Oliguria
Hypotension
Hyperthemia
The Correct Answer is A
A) Edema: Fluid volume overload often leads to edema due to the excess fluid leaking out of the blood vessels into the interstitial spaces. This swelling is commonly observed in areas such as the ankles, legs, and hands.
B) Oliguria: Oliguria, or reduced urine output, is more indicative of fluid volume deficit or kidney dysfunction rather than overload. In fluid volume overload, the kidneys typically produce more urine to try to balance the excess fluid.
C) Hypotension: Fluid volume overload usually causes an increase in blood pressure rather than hypotension. Hypotension is more commonly associated with fluid volume deficit or severe fluid loss.
D) Hyperthermia: Hyperthermia is not a direct result of fluid volume overload. It is more related to conditions involving fever or infection. Fluid overload primarily affects fluid distribution and does not directly cause an increase in body temperature
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Covering the client with a blanket:
Covering the client with a blanket may help manage chills, but it does not address the underlying cause of the symptoms. Stopping the transfusion takes precedence in ensuring patient safety.
B) Assessing the client's skin for a rash:
Assessing for a rash can help determine if an allergic reaction is occurring, but the priority is to stop the transfusion to prevent further complications and address the immediate risk.
C) Notifying the provider:
Notifying the provider is important for reporting and further management, but the immediate action should be stopping the transfusion to prevent potential adverse effects.
D) Stopping the transfusion:
Stopping the transfusion is the priority action as it addresses the immediate risk of a transfusion reaction, such as an allergic reaction or transfusion-related infection. This action helps prevent further complications and ensures the client's safety.
Correct Answer is A
Explanation
A) Mashed potatoes:
Mashed potatoes are an appropriate choice for a soft diet as they are easy to chew and swallow. A soft diet typically includes foods that are tender, moist, and easy to digest, which helps in minimizing difficulty while eating.
B) High-fiber cereals:
High-fiber cereals are not suitable for a soft diet. They can be hard and difficult to chew, and the high fiber content might irritate the digestive tract, making them less ideal for individuals on a soft diet.
C) Fruit with the skin:
Fruits with the skin can be difficult to chew and digest, especially for those on a soft diet. The skin of fruits can be tough and may not be appropriate for someone needing a diet with soft, easily manageable foods.
D) Raw vegetables:
Raw vegetables are typically hard and require thorough chewing, which makes them unsuitable for a soft diet. Soft diets require foods that are tender and easy to chew, so raw vegetables do not meet these criteria.
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