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 C
Explanation
Creating a schedule of daily tasks can help provide structure and routine for individuals with Alzheimer's disease. Having a predictable routine can reduce confusion and frustration by providing a sense of familiarity and stability. The schedule should include activities that the client enjoys and can manage within their abilities. It can help the client feel more organized and engaged throughout the day.
Limiting the use of familiar objects is not recommended. Familiar objects can provide comfort and a sense of security for individuals with Alzheimer's disease. They can help trigger memories and create a sense of familiarity in their environment. Removing familiar objects may increase disorientation and frustration.
Asking questions that require more than one answer can be overwhelming for individuals with Alzheimer's disease. Complex questions can lead to confusion and frustration as the person may struggle to recall or process information. It is best to ask simple and direct questions that can be easily understood and answered.
Having several family members visit daily may cause additional stress and confusion for the client with Alzheimer's disease. Too many visitors can be overwhelming and may disrupt the person's routine or environment. It is important to consider the individual's preferences and abilities when planning visits and ensure that they are manageable and supportive for the client's well-being.
Correct Answer is C
Explanation
Ciprofloxacin is a fluoroquinolone antibiotic that can make the skin more sensitive to sunlight, leading to an increased risk of sunburn. It is important for the client to be aware of this potential side effect and take appropriate precautions, such as using sunscreen, wearing protective clothing, and avoiding prolonged sun exposure while taking the medication.
"Take an antacid if the medication causes gastrointestinal upset." Ciprofloxacin should not be taken with antacids or mineral supplements containing calcium, magnesium, aluminum, or iron, as they can interfere with the absorption of the medication. If the client experiences gastrointestinal upset, they should consult their healthcare provider for appropriate management.
"Restrict your daily fluid intake while taking this medication." It is important for the client to maintain adequate hydration while taking ciprofloxacin, as it is important for the elimination of the medication from the body. Restricting fluid intake can lead to dehydration and may affect the effectiveness of the medication. The client should be encouraged to drink plenty of fluids unless otherwise instructed by their healthcare provider.
"Expect to experience diarrhea while taking this medication." While gastrointestinal side effects such as diarrhea can occur with ciprofloxacin, it is not appropriate to state that the client should expect to experience it. Diarrhea can be a sign of a serious adverse reaction, such as Clostridium difficile infection, and should be reported to the healthcare provider for further evaluation and management.
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