A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?

Bradycardia

Oliguria

Peripheral edema

Hypotension

Answer and Explanation

The Correct Answer is C

A. Bradycardia:
Explanation: Bradycardia refers to a slow heart rate. In hypervolemia (fluid overload), the heart often compensates by increasing the heart rate rather than causing bradycardia.

B. Oliguria:
Explanation: Oliguria refers to decreased urine output. In hypervolemia, the increased fluid volume can lead to increased urine output rather than oliguria.

C. Peripheral Edema:
Explanation: Peripheral edema, or swelling in the extremities, is a common manifestation of hypervolemia. Excess fluid can accumulate in the tissues.

D. Hypotension:
Explanation: Hypertension, not hypotension, is more commonly associated with hypervolemia. The increased volume of fluid in the blood vessels can lead to elevated blood pressure.

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Correct Answer is B

Explanation

A. BUN (Blood Urea Nitrogen):
Explanation: BUN is a measure of kidney function and hydration status. It is not typically elevated in response to a localized infection like a pressure ulcer.

B. WBC count (White Blood Cell count):
Explanation: An elevation in the WBC count is a common indicator of infection. Increased white blood cells suggest the body's immune response to an infection.

C. Potassium:
Explanation: Potassium levels are not typically used to indicate the presence of infection. Elevated potassium may be seen in conditions affecting kidney function.

D. RBC count (Red Blood Cell count):
Explanation: The RBC count is not a specific marker for infection. It is more related to issues such as anemia or oxygen-carrying capacity.

A. Proliferation B. Inflammation C. Maturation D. Remodeling phase

Correct Answer is B

Explanation

A. Proliferation Phase:
Explanation: This phase involves the formation of new tissue to fill the wound space. It includes granulation tissue formation and wound contraction.

B. Inflammation Phase:
Explanation: This is the initial phase characterized by hemostasis and inflammation, aimed at stopping bleeding and preventing infection. Blood vessels constrict, platelets aggregate, and inflammatory cells arrive at the wound site.

C. Maturation Phase:
Explanation: Also known as the remodeling phase, it involves the remodeling and realignment of collagen fibers and the strengthening of scar tissue.

D. Remodeling Phase:
Explanation: Remodeling and maturation are often considered together as the final stage of wound healing, where collagen fibers reorganize and gain strength.

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A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?

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Naxlex Comprehensive Predictor Exams

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