A nurse is assessing a client who has fluid overload. Which of the following findings
should the nurse expect? (Select all that apply.)
A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rat
...
A nurse is assessing a client who has fluid overload. Which of the following findings
should the nurse expect? (Select all that apply.)
A. Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
D. Increase hematocrit
E. Increased temperature
Increased heart rate
B. Increased blood pressure
C. Increased respiratory rate
A nurse is caring for a client who is prescribed warfarin therapy for an artificial heart
valve. Which of the following laboratory values should the nurse monitor for a
therapeutic effect of warfarin?
prothrombin time
.A nurse is assessing a client who is receiving one unit of packed RBCs to treat
intraoperative blood loss. The client reports chills and back pain, and the client's blood
pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?
stop the infusion of blood
.A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen
minutes following the start of the transfusion, the nurse notes that the client is febrile,
with chills and red-tinged urine. Which of the following transfusion reactions should the
nurse suspect?
hemolytic
A nurse in an emergency department is caring for a client who had a seizure and
became unresponsive after stating she had a sudden, severe headache and vomiting.
The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of
82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the
following neurologic disorders should the nurse suspect?
hemorrhagic stroke
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A nurse is caring for a client who returns to the nursing unit from the recovery room after
a sigmoid colon resection for adenocarcinoma. The client had an episode of
intraoperative bleeding. Which finding indicates to the nurse that the client may be
developing hypovolemic shock
increase heart rate ftom 88 to 110/min
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to
his NPO status. Which of the following solutions should the nurse prepare to infuse for
this client?
0.45% sodium chloride
A nurse is caring for a client who has pericarditis and reports feeling a new onset of
palpitations and shortness of breath. Which of the following assessments should
indicate to the nurse that the client may have developed atrial fibrillation?
different apical and radial pulses
A nurse is assessing a client's radial pulse and determines that the pulse is irregular.
Which of the following actions should the nurse takeassess the apical pulse for a full minute
A nurse is assessing an older adult client who is receiving digoxin. The nurse should
recognize that which of the following findings is a manifestation of digoxin toxicity?
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