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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. This describes a second-degree heart block, specifically Mobitz Type I (Wenckebach).
B. A PR interval greater than 0.20 seconds is characteristic of first-degree heart block.

C. This describes third-degree heart block, also known as complete heart block.
D. An irregular R-R interval is not specific to first-degree heart block.
Correct Answer is C
Explanation
Rationale:
A. This is wrong because the ECG leads show ST segment elevation.
B. Stable angina may present with ST segment depression in an ECG unlike in the strip shown above which depicts an ST segment elevation.
C. This is correct because of the ST segment elevation.
D. Unstable angina may have hyperacute T wave, flattening of the T waves, inverted T waves or an ST depression unlike in the above ECG strip.
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