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 are not typically indicative of fluid overload. They may suggest decreased gastrointestinal motility, but this finding alone does not specifically indicate fluid overload.
B. Bradycardia is not typically associated with fluid overload. Instead, tachycardia may occur as the body attempts to compensate for decreased cardiac output.
C. Hypotension may occur with fluid overload in severe cases, but it is not a consistent or specific finding. Other signs, such as bounding pulses, are more indicative of fluid overload.
D. Bounding pulses, or strong and forceful arterial pulses, can be a sign of fluid overload due to increased blood volume. This finding may be observed in clients receiving excessive enteral feedings or intravenous fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Rationale: The recommended hepatitis vaccine series does not consist of four vaccines. The Advisory Committee on Immunization Practices (ACIP) recommends a 3-dose series for most individuals, which includes doses at birth, 1-2 months, and 6-18 months.
Choice B Rationale: Hepatitis B is not typically transmitted by contaminated food. It is primarily spread through exposure to infectious blood, semen, and other body fluids. Transmission can occur through direct contact with blood or body fluids of an infected person, unprotected sex, sharing needles, or from mother to child at birth.
Choice C Rationale: While chronic hepatitis C has been associated with an increased risk of developing renal cell carcinoma, the evidence linking chronic hepatitis B with renal cell cancer is less clear. Some studies suggest a potential association, but it is not established as a common complication.
Choice D Rationale: Individuals with a history of hepatitis B or C are generally ineligible to donate blood. This is due to the risk of bloodborne transmission of these viruses. Even if the individual has recovered or been cured of hepatitis C, they are still barred from donating blood or plasma.
Correct Answer is D
Explanation
A. Portable suction may be needed for some infants but is not specifically indicated for tetralogy of Fallot.
B. A cervical collar is used for neck support in patients with suspected cervical spine injuries and is not indicated for tetralogy of Fallot.
C. A hemodialyzer is used for renal replacement therapy and is not indicated for tetralogy of Fallot.
D. A pulse oximeter is essential for monitoring oxygen saturation levels in infants with tetralogy of Fallot, as they may experience cyanosis and hypoxemia. Monitoring oxygen saturation helps guide interventions and management.
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