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
A. Insisting on direct eye contact may be uncomfortable or distressing for some clients, particularly those with certain mental health conditions or cultural backgrounds. It's important to respect the client's comfort level.
B. Seating the client too far away can create a sense of distance and may hinder effective communication. A closer seating arrangement facilitates rapport and engagement.
C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially if they have concerns about their safety or autonomy.
D. Leaning in slightly when speaking to the client demonstrates attentiveness and engagement. It can also convey a sense of confidentiality and respect for the client's space.
Correct Answer is B
Explanation
A. Crepitus is not typically associated with right ventricular heart failure; it may indicate subcutaneous emphysema or air leakage into the tissues.
B. Right ventricular heart failure often leads to elevated pulmonary artery pressure due to increased pressure in the pulmonary circulation.
C. Hepatosplenomegaly may occur in congestive heart failure but is not specific to right ventricular heart failure.
D. Confusion may occur in severe cases of heart failure due to decreased cerebral perfusion, but it is not specific to right ventricular heart failure.
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