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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 C

Explanation

Rationale:

A. Salt substitutes often contain potassium and should be avoided in clients with hyperkalemia.

B. Citrus juices and bananas are high in potassium and should be avoided in clients with hyperkalemia.

C. A 12-lead ECG may include changes such as peaked T wave, flattened P wave, prolonged PR interval, ST depression, and prolonged QRS duration.

D. A serum sodium level should be obtained but it is not the priority in this case.

A. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. B. It is okay to skip a dose of diuretic. C. Check weight daily when it is easiest. D. Call the provider if you gain 2 lbs. in 24 hours

Correct Answer is D

Explanation

Rationale:

A. A weight gain of 0.5 kg (1 lb) in a week is not typically concerning for heart failure exacerbation.

B. Skipping a dose of a diuretic can lead to fluid retention and exacerbate heart failure symptoms.

C. Weighing daily is important for monitoring fluid retention, but the specific time of day is not as crucial as consistent timing.

D. A weight gain of 2 lbs. in 24 hours can indicate fluid retention and worsening heart failure.

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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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