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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Correct. Measuring abdominal girth daily is important to monitor for changes in ascites and fluid retention.
B. Restricting sodium intake is important for clients with ascites to manage fluid retention, but a specific limit of 3 g per day is not universally applicable.
C. Protein intake should not be significantly restricted for clients with ascites; protein is essential for maintaining adequate serum albumin levels.
D. Positioning the client supine with legs elevated might be uncomfortable and not directly related to managing ascites.

A. Applying the stockings before the client gets out of bed B. Turning the stockings inside out before applying them C. Asking the client to point their toes before applying the stockings D. Ensuring that creases in the stockings are on the front of the client's legs

Correct Answer is D

Explanation

Correct. Applying ant embolic stockings while the client is still in bed helps prevent venous stasis.
Incorrect. Turning the stockings inside out is not a correct step in the application process and should be corrected by the nurse.
Correct. Asking the client to point their toes helps ensure proper positioning of the stockings.
Ensuring that creases are on the front of the legs helps prevent pressure points.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has ascites due to cirrhosis. Which of the following interventions should the nurse recommend to include in the plan?

Correct Answer is A

Explanation

A nurse is supervising an assistive personnel (AP. who is applying anti-embolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?

Correct Answer is D

Explanation

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