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. Compulsive attention to details: This behavior is more characteristic of obsessive-compulsive personality disorder rather than antisocial personality disorder.
B. Avoids interacting with others: Antisocial personality disorder is characterized by a disregard for and violation of the rights of others, but avoidance of social interaction is not a typical
feature.
C. Uses others for personal gain: This behavior aligns with the manipulative and exploitative tendencies often seen in individuals with antisocial personality disorder.
D. Socially awkward in group situations: While individuals with antisocial personality disorder may have difficulty forming meaningful relationships, they often have superficial charm and can be socially adept, so being socially awkward in group situations is less indicative of this disorder.
Correct Answer is A
Explanation
A.
A. Profuse milky white discharge: Bacterial vaginosis is characterized by a fishy odor and a thin, homogeneous, grayish-white discharge, not milky white. However, this option is the most closely associated with bacterial vaginosis among the choices provided.
B. Frequency and dysuria: These symptoms are more indicative of urinary tract infection rather than bacterial vaginosis.
C. Low-grade fever: Fever is not typically associated with bacterial vaginosis unless there is a secondary infection present.
D. Hematuria: Hematuria, or blood in the urine, is not a typical symptom of bacterial vaginosis.
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