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 D

Explanation

A. "I will cover the catheter so he cannot see it."
Explanation: This statement suggests attempting to hide the feeding tube from the client. However, addressing the issue of attempting to remove the feeding tube requires a more comprehensive approach, and simply covering the catheter may not address the root cause.

B. "Let me provide more stimulation in his environment."
Explanation: This statement suggests increasing environmental stimulation. While environmental interventions can be considered, it's important to address the specific behavior and assess whether increased stimulation is an appropriate and effective intervention. It may not directly address the issue of attempting to remove the feeding tube.

C. "Let's wait until tonight to see if he continues this behavior."
Explanation: This statement suggests a passive approach of waiting to see if the behavior persists. However, if a client is attempting to remove a feeding tube, it's important to address the issue promptly to prevent potential harm or complications. Waiting may not be the most proactive approach in this situation.

D. "I will call the doctor and get the prescription."
Explanation: This is the most appropriate choice. Applying restraints requires a healthcare provider's order. The nurse should communicate with the doctor to discuss the client's behavior, assess the need for restraints, and obtain the necessary prescription if deemed appropriate. This ensures a lawful and ethical approach to using restraints.

A. "Sweating can occur with hypoglycemia." B. "My son might complain of feeling shaky when he has a low blood glucose level." C. "My son might have nausea and vomiting with hypoglycemia." D. "The onset of low blood glucose usually occurs rapidly."

Correct Answer is D

Explanation

A. "Sweating can occur with hypoglycemia."
Explanation: This statement is correct. Sweating is one of the common symptoms of hypoglycemia. When blood glucose levels drop too low, the body releases stress hormones, including adrenaline, which can lead to sweating.

B. "My son might complain of feeling shaky when he has a low blood glucose level."
Explanation: This statement is correct. Shaking or feeling shaky is a common symptom of hypoglycemia. It results from the release of stress hormones in response to low blood glucose.

C. "My son might have nausea and vomiting with hypoglycemia."
Explanation: This statement is correct. Nausea and vomiting can be symptoms of hypoglycemia. While not everyone with low blood glucose will experience these symptoms, they are possible manifestations.

D. "The onset of low blood glucose usually occurs rapidly."
Explanation: This statement is generally true, but it can vary. The onset of hypoglycemia can happen rapidly, especially if the individual has taken a fast-acting insulin or medication. However, the speed of onset can depend on various factors, and it's important to emphasize that it may not always be immediate.

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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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