A nurse is collecting data on a client who has circulatory overload. Which of the following findings should the nurse expect?

Tachycardia

Weight loss

Hypotension

Diaphoresis

Answer and Explanation

The Correct Answer is A

Choice A reason: Tachycardia is a sign of circulatory overload. Circulatory overload is a condition where the blood volume or rate of infusion is too high for the client's cardiovascular system. This causes the heart to beat faster and harder to pump the excess fluid, resulting in a high heart rate, or tachycardia.

Choice B reason: Weight loss is not a sign of circulatory overload. Weight loss is a condition where the body loses more calories than it consumes, resulting in a decrease in body mass. Weight loss can be caused by various factors, such as diet, exercise, illness, or medication. Weight gain, not weight loss, is a sign of circulatory overload, as the excess fluid accumulates in the body.

Choice C reason: Hypotension is not a sign of circulatory overload. Hypotension is a condition where the blood pressure is too low, which can impair the blood flow to the vital organs. Hypotension can be caused by various factors, such as dehydration, bleeding, shock, or medication. Hypertension, not hypotension, is a sign of circulatory overload, as the excess fluid increases the pressure in the blood vessels.

Choice D reason: Diaphoresis is not a sign of circulatory overload. Diaphoresis is a condition where the body sweats excessively, which can help to regulate the body temperature and eliminate toxins. Diaphoresis can be caused by various factors, such as fever, anxiety, exercise, or medication. Edema, not diaphoresis, is a sign of circulatory overload, as the excess fluid leaks into the interstitial spaces and causes swelling.

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Correct Answer is A

Explanation

Choice A reason: Leakage of urine is a sign of urinary retention, as it indicates that the bladder is overdistended and unable to empty completely. The urine may leak around the urethra or through a catheter.

Choice B reason: Dark-colored urine is not a sign of urinary retention. It can be caused by dehydration, certain foods or medications, or liver or kidney problems.

Choice C reason: Cloudy urine is not a sign of urinary retention. It can be caused by infection, inflammation, or stones in the urinary tract.

Choice D reason: Blood in urine is not a sign of urinary retention. It can be caused by trauma, infection, cancer, or coagulation disorders in the urinary tract.

A. Every 2 hr while the client is awake B. When the client has the urge to defecate C. Immediately before meals D. After the client feels abdominal cramping

Correct Answer is B

Explanation

Choice A: Taking the client to the bathroom every 2 hours while awake is not an effective strategy for bowel training. This may disrupt the client's natural bowel rhythm and cause unnecessary stress and frustration. Bowel training aims to establish a regular and predictable time for elimination, not a frequent and arbitrary one¹².
Choice B: Taking the client to the bathroom when they have the urge to defecate is the best option for bowel training. This helps the client to respond to their body's signals and avoid suppressing or delaying the urge. It also reinforces the association between the urge and the act of defecation, which can improve bowel control and prevent constipation¹².
Choice C: Taking the client to the bathroom immediately before meals is not a good idea for bowel training. This may interfere with the client's appetite and digestion, as well as their social and emotional well-being. Bowel training should not be associated with negative or unpleasant feelings. Moreover, eating stimulates the gastrocolic reflex, which increases the motility of the colon and the likelihood of having a bowel movement after a meal¹³.
Choice D: Taking the client to the bathroom after they feel abdominal cramping is not a reliable method for bowel training. Abdominal cramping may indicate various conditions, such as irritable bowel syndrome, food intolerance, infection, or inflammation. It may not always be related to the need to defecate. Waiting for cramping to occur may also delay the evacuation and worsen the symptoms¹³.

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A nurse is collecting data on a client who has circulatory overload. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who has urinary retention. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is assisting with the implementation of a bowel training program for a client. For the program to be effective, the nurse should take the client to the bathroom at which of the following times?

Correct Answer is B

Explanation

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