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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Clear fluid drainage from the nares, especially if it is continuous or persistent, may indicate a cerebrospinal fluid (CSF) leak, which can occur with a skull fracture.

B. Pain around the eyes is more commonly associated with a nasal fracture or orbital fracture, rather than a skull fracture.

C. Dried blood in the mouth may indicate nasal bleeding but does not necessarily indicate a skull fracture.

D. Mandibular asymmetry may indicate a jaw fracture or injury but is not typically associated with a skull fracture.

A. Insert an indwelling catheter if the client has not voided in 3 hr. B. Obtain the abdominal girth now and every 4 hr. C. Assess and document the level of consciousness every hour. D. Measure the amount of gastric drainage every 2 hr. E. None F. None

Correct Answer is D

Explanation

A. Inserting an indwelling catheter involves an invasive procedure and assessment of urinary output and client status, which falls within the RN’s scope of practice in a high-risk client such as one with acute liver failure.

B. Obtaining abdominal girth requires assessment skills and interpretation for changes in ascites, which is more appropriate for the RN to ensure accurate monitoring.

C. Assessing and documenting level of consciousness is a critical assessment, especially in liver failure where hepatic encephalopathy is a risk. This is within the RN’s responsibility because changes can be subtle and require immediate intervention.

D. Measuring the amount of gastric drainage every 2 hours is a stable, routine task that follows established parameters and does not require advanced assessment skills. It is within the LPN’s scope and can be safely delegated, with the RN overseeing interpretation of any abnormal findings.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is assessing a client who has a nasal fracture. Which of the following findings should cause the nurse to suspect a skull fracture?

Correct Answer is A

Explanation

A nurse delegates tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). When admitting a client who is experiencing acute liver failure and who has ascites and an NG tube, which of the following tasks is most appropriate for the nurse to delegate to the LPN?

Correct Answer is D

Explanation

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