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A nurse is caring for a heart failure client with a history of dietary non compliance. The nurse suspects the client has fluid volume overload. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY))

Increased blood pressure

increased heart rate

Increase hematocrit

Increased respiratory rate

Increased temperature

Answer and Explanation

Correct Answer : A,B,D

Rationale:

A. Fluid overload can lead to increased blood pressure due to the excess fluid circulating in the body.

B. Increased heart rate is a compensatory mechanism in response to fluid volume overload.

C. Increased hematocrit is not typically associated with fluid volume overload.

D. Increased respiratory rate is a compensatory mechanism in response to fluid volume overload.

E. Increased temperature is not typically associated with fluid volume overload.

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Correct Answer is A

Explanation

Rationale:

A. Mitral valve regurgitation typically presents with a murmur, which is a characteristic sound associated with the backflow of blood into the left atrium during systole.

B. S3 and S4 are not typical heart sounds and do not relate to mitral valve regurgitation.

C. A click is typically associated with mitral valve prolapse, not mitral valve regurgitation.

D. A friction rub is typically associated with pericarditis, not mitral valve regurgitation.

A. Swelling at the insertion site and cool extremity B. Oozing blood from the insertions site C. The client has not voided since returning to recovery. D. Blood pressure reading of 110/70 and heart rate of 90

Correct Answer is A

Explanation

Rationale:

A. Swelling at the insertion site and cool extremity may indicate bleeding or hematoma formation at the site.

B. Oozing blood from the insertion site is expected immediately after a cardiac catheterization.

C. The client has not voided since returning to recovery is not related to the cardiac catheterization.

D. Blood pressure reading of 110/70 and heart rate of 90 are within normal limits.

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A nurse is caring for a heart failure client with a history of dietary non compliance. The nurse suspects the client has fluid volume overload. Which of the following findings should the nurse expect? (SELECT ALL THAT APPLY))

Nursing Test Bank

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