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 {"dropdown-group-1":"E","dropdown-group-2":"B"}
Explanation
When interpreting test results, particularly for an infectious disease like tuberculosis (TB), the nurse must prioritize specific infection control measures to prevent the spread of the disease.
The correct actions are:
- Wear an N95 respirator mask: This mask is essential for protecting the nurse and others from inhaling airborne pathogens that the client with TB might expel.
- Place the client in a room with negative air pressure: This type of room ensures that airborne contaminants do not escape into the hallway or other areas, thereby containing the infection and protecting others in the healthcare facility.
These measures are critical in managing the spread of TB and ensuring the safety of both healthcare workers and other patients.
Correct Answer is C
Explanation
A. Placing a pillow between the legs can actually provide support and comfort when lying on the back or non-operative side.
B. Gentle exercises are typically encouraged after hip arthroplasty to promote circulation and prevent complications.
C. Correct. Avoiding lying on the operative side helps prevent dislocation of the new hip joint.
D. Avoiding crossing the legs helps prevent hip joint stress, but avoiding lying on the operative side is more crucial.
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