Difficulty: Medium
Average Score: 87%
Simulated
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
Correct answer
A,C,D
Rationale
Correct Answer: A, C, D
Rationale:
- Increased respiratory rate (A) is expected due to pulmonary congestion from fluid overload.
- Increased heart rate (C) occurs as the heart works harder to pump excess fluid throughout the body.
- Increased blood pressure (D) is a compensatory mechanism to maintain perfusion.
- Increased temperature (B) is not typically associated with fluid overload.
- Increased hematocrit (E) is actually decreased in fluid overload due to hemodilution.
Overall, A, C, and D are the expected findings in a client with fluid overload, while B and E are not typically seen in this condition.
Rationale:
- Increased respiratory rate (A) is expected due to pulmonary congestion from fluid overload.
- Increased heart rate (C) occurs as the heart works harder to pump excess fluid throughout the body.
- Increased blood pressure (D) is a compensatory mechanism to maintain perfusion.
- Increased temperature (B) is not typically associated with fluid overload.
- Increased hematocrit (E) is actually decreased in fluid overload due to hemodilution.
Overall, A, C, and D are the expected findings in a client with fluid overload, while B and E are not typically seen in this condition.