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 ["92"]

Explanation

Pulse pressure is the difference between systolic and diastolic blood pressure.
The client's pulse pressure is 132 - 40 = 92 mm Hg.

A. A client who has heart failure and reports shortness of breath while ambulating B. A client who has abdominal pain and is vomiting coffee-ground emesis C. A client who has benign prostatic hyperplasia and is unable to urinate D. A client who had an open cholecystectomy and has green drainage from the T-tube

Correct Answer is B

Explanation

A. This client's symptom of shortness of breath while ambulating indicates possible worsening heart failure, which requires prompt assessment but is not immediately life-threatening.

B. Vomiting coffee-ground emesis suggests upper gastrointestinal bleeding, which could be

indicative of a serious condition such as a gastrointestinal ulcer or tear and requires immediate assessment to determine the cause and initiate appropriate treatment.

C. While urinary retention in a client with benign prostatic hyperplasia requires attention, it is not as urgent as upper gastrointestinal bleeding.

D. Green drainage from the T-tube in a client who had an open cholecystectomy may indicate bile leakage, which requires assessment and intervention, but upper gastrointestinal bleeding takes precedence due to its potential for rapid deterioration.

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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

Correct Answer is ["92"]

Explanation

A nurse is caring for a group of clients. Which of the following clients should the nurse assess first?

Correct Answer is B

Explanation

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