A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings indicates fluid overload?
Diminished bowel sounds
Bradycardia
Hypotension
Bounding pulses
The Correct Answer is D
A. Diminished bowel sounds: Diminished bowel sounds indicate decreased gastrointestinal motility or possible ileus, but they are not a sign of fluid overload. This finding is unrelated to the client’s fluid status.
B. Bradycardia: Bradycardia refers to a slow heart rate, which is more often associated with conduction abnormalities, medications, or vagal stimulation. It does not typically indicate fluid overload.
C. Hypotension: Hypotension usually reflects fluid deficit, blood loss, or cardiovascular compromise. Fluid overload is more likely to cause hypertension rather than low blood pressure.
D. Bounding pulses: Bounding pulses are a classic cardiovascular manifestation of fluid overload. Excess intravascular volume increases stroke volume and arterial pressure, resulting in strong, forceful pulses, making this an important sign for the nurse to recognize.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Holding the newborn in an en face position: Positioning the newborn face-to-face with the parent promotes eye contact and bonding. This action supports healthy attachment and is encouraged during early interactions.
B. Asking the father to change the newborn's diaper: Involving another caregiver in newborn care is appropriate and promotes family bonding. It does not indicate a problem with maternal-infant attachment.
C. Viewing the newborn's actions to be uncooperative: Interpreting normal newborn behaviors, such as crying or squirming, as deliberate uncooperativeness may indicate difficulty in bonding or unrealistic expectations. The nurse should intervene to provide guidance on normal newborn behavior and support attachment.
D. Requesting the nurse take the newborn to the nursery so she can rest: Asking for rest is appropriate, especially if the mother is fatigued. Temporary separation does not negatively impact bonding if the mother is able to interact and care for the newborn afterward.
Correct Answer is C
Explanation
A. Shakiness: Shakiness is typically a manifestation of hypoglycemia, resulting from activation of the sympathetic nervous system. It occurs when blood glucose drops below normal levels, not with hyperglycemia, so it is not associated with a glucose level of 265 mg/dL.
B. Confusion: Confusion can occur with both severe hyperglycemia and hypoglycemia, but it is more pronounced in extreme elevations of blood glucose or in hyperosmolar hyperglycemic states. A level of 265 mg/dL may not yet cause marked cognitive changes in all clients.
C. Thirst: Hyperglycemia causes osmotic diuresis, leading to fluid loss and dehydration, which triggers excessive thirst (polydipsia). This is a common and early clinical manifestation associated with elevated blood glucose levels such as 265 mg/dL.
D. Diaphoresis: Diaphoresis, or excessive sweating, is primarily a symptom of hypoglycemia caused by adrenergic stimulation. It is not a typical manifestation of hyperglycemia and is unlikely to occur with a blood glucose of 265 mg/dL.
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