The nurse is assessing a client diagnosed with fluid overload. The nurse should implement priority interventions for which of the following assessment findings? (Select all that apply.)

Increased temperature

Increase hematocrit

Blood pressure 180/100

Respiratory rate 32

Heart rate 120bpm

Answer and Explanation

Correct Answer : C,D

A. Increased temperature: Fluid overload typically doesn't cause an increased temperature. Infections or other inflammatory processes are more likely causes of elevated body temperature.

B. Increased hematocrit: Fluid overload usually results in dilution of blood components, leading to a decreased hematocrit (lower concentration of red blood cells in the blood). An increased hematocrit is not a typical finding in fluid overload.

C. Blood pressure 180/100: Elevated blood pressure can be associated with fluid overload, especially if the overload is chronic. This is a correct assessment finding that requires intervention and monitoring.

D. Respiratory rate 32: An increased respiratory rate can be a sign of respiratory distress, which may occur in severe cases of fluid overload, especially if it leads to pulmonary edema. This is a correct assessment finding that requires intervention and further evaluation.

E. Heart rate 120 bpm: An increased heart rate can be a compensatory mechanism in response to fluid overload, especially if the heart is trying to maintain cardiac output. However, this heart rate alone is not specific enough to confirm fluid overload. Other signs and symptoms, such as edema, increased blood pressure, and respiratory distress, are more indicative of fluid overload.

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Correct Answer is A

Explanation

A. Atelectatic crackles that do not have a pathologic cause:

Atelectatic crackles are short, popping, crackling sounds heard during auscultation. They occur in individuals who are in a supine position and disappear after a few breaths. These crackles are not indicative of any pathological condition; they are common when the lungs are not fully aerated, especially when a person is lying down.

B. Vesicular breath sounds:

Vesicular breath sounds are normal lung sounds heard over the peripheral lung areas. They are soft, low-pitched, and continuous throughout inspiration and part of expiration. Vesicular breath sounds are the typical sounds heard during routine breathing and are not associated with crackling or popping noises.

C. Fine wheezes:

Wheezes are high-pitched whistling sounds heard during expiration. They occur due to narrowed airways and are commonly associated with conditions like asthma or bronchoconstriction. Fine wheezes suggest a partial obstruction in the smaller airways, causing turbulent airflow, leading to the characteristic sound.

D. Fine crackles and may be a sign of pneumonia:

Fine crackles are high-pitched, discontinuous, crackling sounds heard during inspiration. They can occur due to the sudden opening of small airways, and their presence may indicate fluid in the lungs or lung inflammation. Fine crackles are often associated with conditions such as pneumonia, heart failure, or interstitial lung diseases.

A. Maxillary sinusitis B. Nasal polyps. C. Frontal sinusitis. D. Posterior epistaxis.

Correct Answer is A

Explanation

A. Maxillary sinusitis:

Explanation: The client's symptoms of facial pain, fever, malaise, swollen turbinates, purulent nasal discharge, and dull, throbbing pain in the cheeks and teeth on the right side, especially when palpated, are indicative of maxillary sinusitis. Maxillary sinusitis refers to the inflammation of the maxillary sinuses, which are located in the cheek area. The symptoms described align with a bacterial infection in this sinus.

B. Nasal polyps:

Explanation: Nasal polyps are soft, noncancerous growths on the lining of the nasal passages or sinuses. While they can cause nasal congestion and a runny nose, they do not typically present with the specific symptoms mentioned in the scenario, such as facial pain, fever, and purulent discharge.

C. Frontal sinusitis:

Explanation: Frontal sinusitis involves inflammation of the frontal sinuses located in the forehead area. Symptoms may include forehead pain, headache, and nasal discharge. However, the described symptoms in the scenario (dull, throbbing pain in the cheeks and teeth on the right side) are more characteristic of maxillary sinusitis.

D. Posterior epistaxis:

Explanation: Posterior epistaxis refers to a nosebleed that originates from the back of the nose, often due to bleeding from the sphenopalatine artery. While nosebleeds can cause blood drainage into the throat and result in a metallic taste, the other symptoms described in the scenario, such as facial pain, fever, and purulent discharge, are not indicative of posterior epistaxis.

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The nurse is assessing a client diagnosed with fluid overload. The nurse should implement priority interventions for which of the following assessment findings? (Select all that apply.)

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Correct Answer is A

Explanation

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Explanation

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