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 C

Explanation

- A: Garlic supplements are not contraindicated for clients taking antidepressants. While garlic is known to have a variety of health benefits, there is no well-documented interaction between garlic supplements and antidepressants that would contraindicate their concurrent use.
- B: There is no direct contraindication for the use of garlic supplements in clients with a history of seizure disorders. Garlic supplements do not have a seizure threshold-lowering effect, which is a common concern with some medications and conditions that may exacerbate seizure disorders.
- C: Garlic supplements may increase the risk of bleeding, especially when taken with other substances that have anticoagulant properties, such as aspirin. This is due to garlic's potential effect on platelet aggregation and the blood clotting process, making it a contraindication for clients who take aspirin daily.
- D: Garlic supplements do not have a contraindication for clients with a history of rheumatoid arthritis. In fact, some studies suggest that garlic may have anti-inflammatory properties, which could be beneficial for individuals with inflammatory conditions like rheumatoid arthritis.

A. 1 cm of water present in the water seal chamber B. Tidaling with spontaneous respirations C. Suction chamber pressure of -20 cm H20 D. Drainage collection chamber is one-third full

Correct Answer is A

Explanation

A. The water seal chamber should contain at least 2 cm of water to maintain the seal and prevent air from entering the pleural space. Only 1 cm of water is inadequate and requires intervention.
B. Tidaling, or fluctuation of water with respirations, is an expected finding and indicates that the system is functioning properly.
C. A suction chamber pressure of -20 cm H₂O is the standard setting for chest tube drainage systems and does not require intervention.
D. A drainage collection chamber that is one-third full is within normal limits and simply indicates the need to continue monitoring output.

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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 is reviewing the medical history of a client who is taking a garlic supplement. The nurse should identify that which of the following findings is a contraindication for taking this supplement?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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