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 C
Explanation
A. The child develops a dry, hacking cough: This suggests ineffective clearance of secretions and may indicate a need for further intervention.
B. The child has increased nasal secretions: Nasal secretions are not directly related to the effectiveness of high-frequency chest compressions in clearing pulmonary secretions.
C. The child has increased sputum production: Increased sputum production indicates that the
treatment is effectively mobilizing and clearing mucus from the airways, which is beneficial for a child with cystic fibrosis.
D. The child develops diminished breath sounds: Diminished breath sounds could indicate a complication such as atelectasis or pneumothorax and would not be an expected finding with effective high-frequency chest compressions.
Correct Answer is D
Explanation
A. Herpes simplex virus 2: Herpes simplex virus infections are not typically reportable to the
Centers for Disease Control and Prevention (CDC). These infections are commonly managed at the local level.
B. Candida albicans: Candida albicans infections are not typically reportable to the CDC. Candida species are common pathogens and are usually managed at the local level.
C. Staphylococcus aureus: Staphylococcus aureus infections, including methicillin-resistant
Staphylococcus aureus (MRSA), are not typically reportable to the CDC unless part of a larger outbreak or public health concern.
D. Lyme disease: Lyme disease is a reportable infection that requires notification to public health authorities, including the Centers for Disease Control and Prevention (CDC). Lyme disease is a vector-borne illness transmitted through the bite of infected ticks.
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