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NurseDive Free Nursing Practice Question
A nurse is assessing a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?
A. Oliguria
B. Peripheral edema
Peripheral edema refers to the swelling of the extremities, such as the hands, feet, and ankles, which is a common manifestation of hypervolemia. It occurs due to an excessive accumulation of fluid in the interstitial spaces. Oliguria, which refers to decreased urine output, is more commonly associated with conditions like dehydration or hypovolemia (fluid volume deficit). In hypervolemia, the kidneys may still be able to produce an adequate amount of urine. Hypotension, or low blood pressure, is not commonly seen in hypervolemia. Increased fluid volume leads to increased blood volume, which can result in elevated blood pressure rather than hypotension. Bradycardia, a slower heart rate, is not typically associated with hypervolemia. In fact, hypervolemia can sometimes lead to an increased heart rate as the heart works harder to pump the excess fluid throughout the body.
C. Hypotension
D. Bradycardia
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med surg exam 1A Proctored Exam. Take the full exam now
Similar Questions
A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?
A. Respiratory acidosis
The pH of 7.3 indicates acidemia (a lower-than-normal blood pH), and the PaCO2 of 50 mm Hg indicates hypercapnia (an elevated level of carbon dioxide in the blood). Together, these findings indicate respiratory acidosis, which is an acid-base imbalance that occurs when the lungs are unable to remove enough carbon dioxide from the body, leading to an accumulation of carbonic acid in the blood. Metabolic acidosis, on the other hand, is an acid-base imbalance that occurs due to an excess of acid or a loss of bicarbonate in the body, resulting in a low pH and a low bicarbonate level. Respiratory alkalosis is an acid-base imbalance that occurs when there is a decreased level of carbon dioxide in the blood, resulting in an elevated blood pH. Metabolic alkalosis is an acid-base imbalance that occurs due to an excess of bicarbonate in the body, resulting in an elevated pH and a high bicarbonate level.
B. Metabolic acidosis
C. Respiratory alkalosis
D. Metabolic alkalosis
A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect?
A. Lethargy
Lethargy and/or altered mental status: Respiratory acidosis can lead to a decrease in the pH of the blood, resulting in acidemia. Acidemia affects the central nervous system and can cause lethargy, confusion, and other alterations in mental status. Other findings associated with respiratory acidosis may include: Headache Tachycardia (increased heart rate) Hypoventilation (shallow or slow breathing) Shortness of breath or difficulty breathing Cyanosis (bluish discoloration of the skin and mucous membranes due to decreased oxygenation) Decreased blood pressure Abdominal pain, dry skin, and numbness of fingers are not typically associated with respiratory acidosis. These findings may be more indicative of other conditions or imbalances.
B. Abdominal pain
C. Dry skin
D. Numbness of fingers
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
A. Scatter rugs are present in the kitchen.
Scatter rugs can pose a significant tripping hazard, especially for individuals with visual impairments. They are often not securely fastened to the floor, making them prone to slipping or sliding. If the client cannot see them clearly due to decreased vision, they may accidentally trip or lose their balance, leading to a fall and potential injuries. Electrical cords placed along the walls can be a tripping hazard if not properly secured or positioned, but they may not pose as high a risk as scatter rugs in terms of causing falls. Using a microwave for cooking is a common and safe method for meal preparation and does not necessarily pose a safety risk for an individual with decreased vision. Handrails present in the bathroom are actually beneficial for enhancing safety and preventing falls. They provide stability and support, especially in areas like the toilet and shower, where the risk of slips and falls is higher.
B. Electrical cords are placed along the walls.
C. Uses a microwave for cooking.
D. Handrails are present in the bathroom.