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. Observing the client during and after meals is a priority because clients with bulimia nervosa often engage in episodes of binge eating followed by purging behaviors. Monitoring the client's behavior during meals and immediately after can help assess for potential purging behaviors.
B. Incorrect. While involving the client in meal planning might be helpful, it is not the first action to address potential purging behaviors.
C. Incorrect. Instructing the client about effective coping strategies is important, but observing for potential purging behaviors is the initial action to address the client's immediate safety.
D. Incorrect. Referring the client to a support group is beneficial, but it is not the first action to address the client's immediate risk of purging behaviors.
Correct Answer is B
Explanation
A. Meningococcal immunization typically includes different schedules and doses; stating three doses before kindergarten is not accurate.
B. Correct. The rotavirus vaccine is administered orally to infants.
C. Feeding restrictions before immunizations are not routinely required for infants.
D. While some mild fever after immunizations is possible, the statement suggests an expectation of a high fever for 24 hours, which is not accurate.
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