A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
Weight loss
Decreased blood pressure
Decreased skin turgor
Crackles heard in the lungs
The Correct Answer is D
A. Incorrect. Weight loss is not a manifestation of fluid overload but rather of insufficient nutrition.
B. Incorrect. Decreased blood pressure is not a manifestation of fluid overload but could indicate hypovolemia.
C. Incorrect. Decreased skin turgor is a sign of dehydration, not fluid overload.
D. Correct. Crackles heard in the lungs can indicate fluid overload in the lungs, also known as pulmonary edema. This is often caused by an excess of fluid in the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. MRSA is spread through direct contact with infected skin or surfaces. Wearing gloves when providing care to a client with MRSA helps prevent the spread of the bacteria.
B. Incorrect. The use of HEPA filters and negative air pressure is typically reserved for airborne infections such as tuberculosis. MRSA is primarily spread through direct contact.
C. Incorrect. Negative air pressure is not typically necessary for preventing the spread of MRSA, which is primarily spread through contact.
D. Incorrect. Wearing a mask when out of the room is not a standard precaution for MRSA, which is not primarily transmitted through the airborne route.
Correct Answer is D
Explanation
Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening skin reaction that can occur as a rare but serious side effect of allopurinol. The initial symptom often presents as a skin rash, which can progress rapidly and involve other mucous membranes such as the mouth and eyes. Fever is commonly associated with SJS.
Diplopia (double vision) is not a typical symptom of SJS. It refers to seeing two images instead of one and can be caused by various factors unrelated to allopurinol or SJS.
Tinnitus with ear pain is not a characteristic symptom of SJS. It usually relates to issues with the auditory system, such as damage to the inner ear or other underlying conditions.
Hyperreflexia (exaggerated reflexes) is not directly associated with SJS. It typically refers to an abnormal increase in the body's reflex responses and can be caused by conditions affecting the central nervous system or spinal cord.
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