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 A
Explanation
A.
A. Gastroenteritis can lead to dehydration and electrolyte imbalances, which can cause lethargy and confusion. This indicates a potentially serious condition requiring immediate attention.
B. While cystic fibrosis requires management, the symptoms described (thick, productive cough and thirst) are not immediately life-threatening.
C. Sickle cell anemia pain is significant but may not require immediate intervention if the client has just received analgesia and is being monitored.
D. While a morning fasting capillary glucose of 185 mg/dL is elevated in a client with diabetes mellitus, it does not require immediate intervention unless accompanied by symptoms of hyperglycemia such as confusion or lethargy.
Correct Answer is D
Explanation
A. The provider is not required to notify the client's employer about the admission to a mental health facility. This information is protected under confidentiality laws and regulations.
B. While the client may be strongly encouraged to take prescribed medications, they cannot be forced to do so without consent, especially if they are competent to make their own decisions.
C. Electroconvulsive therapy (ECT) typically requires informed consent from the patient or their legal representative, even in an involuntary admission scenario. Therefore, it is incorrect to state that ECT can be performed without consent.
D. If the client poses a risk of harm to themselves or others, the provider can prescribe restraints as a safety measure. This statement is correct and aligns with safety protocols in mental health facilities.
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