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. Providing information about the client's pain relief strategies and positioning preferences helps ensure continuity of care and optimal comfort for the client.

B. Incorrect. While medication administration is important, it's not as relevant for the change of shift report as information related to the client's condition, preferences, and care needs.

C. Incorrect. The client's family history of breast cancer is not the most critical information for the immediate care of the client and can be discussed during a more comprehensive assessment.

D. Incorrect. Although family support and visits are important, the duration of the partner's visit is not as relevant as the client's immediate care needs and preferences.

A. Incident report B. Nursing care plan C. Provider's progress notes D. Controlled substance inventory record

Correct Answer is A

Explanation

A. Correct. An incident report should be completed for any unintended event or situation that could have resulted or did result in harm to a patient. Administering the wrong dose of medication falls under this category.
B. Incorrect. The nursing care plan is a comprehensive outline of a patient's care needs and interventions and is not the appropriate place to document a medication error.
C. Incorrect. The provider's progress notes are meant to document the patient's condition, care, and progress, but they are not used to document medication errors.
D. Incorrect. The controlled substance inventory record is used to track the dispensing and administration of controlled substances, not to document medication errors.

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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 providing change of shift report for a client. Which of the following information should the nurse include in the report?

Correct Answer is A

Explanation

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr. PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?

Correct Answer is A

Explanation

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