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. Furosemide is a loop diuretic that helps eliminate excess fluid and sodium from the body by increasing urine production. Increased urinary output is an indication that the medication is effectively managing fluid overload, a common issue in heart failure.
B. Incorrect. While a decreased BUN (blood urea nitrogen. level might occur due to improved kidney function, it is not a direct indicator of furosemide's effectiveness.
C. Incorrect. An increased weight suggests fluid retention, which would not indicate the effectiveness of furosemide.
D. Incorrect. Decreased hemoglobin levels may be due to various factors and are not directly related to the effectiveness of furosemide.
Correct Answer is A
Explanation
A. Correct. Respiratory syncytial virus (RSV. is primarily spread through respiratory droplets.
Initiating droplet precautions, which include wearing a mask and placing the client in a private room, is appropriate to prevent the spread of the virus.
B. Incorrect. Monitoring the preschooler's urine for protein is not relevant to the care of a client with RSV.
C. Incorrect. Fluconazole is an antifungal medication and is not indicated for the treatment of RSV.
D. Incorrect. Requesting an x-ray of the preschooler's neck is not relevant to the care of a client with RSV.
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