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 D

Explanation

A. Incorrect. Coffee can have a diuretic effect and may exacerbate diarrhea.
B. Incorrect. Ice cream is high in fat and lactose, which might worsen diarrhea in some individuals.
C. Incorrect. Apple juice can contribute to diarrhea due to its high sugar content and potential for malabsorption.
D. Correct. Yogurt contains probiotics (live beneficial bacteria. that can help restore and maintain a healthy balance of gut bacteria, potentially reducing the occurrence of antibiotic-associated diarrhea.

A. Wear shoes with rubber soles. B. Conduct change of shift reports near the clients' rooms. C. Open curtains between clients in semi-private rooms. D. Turn on overhead lights briefly when checking IV lines.

Correct Answer is A

Explanation

The correct answer is choice a. Wear shoes with rubber soles.

Choice A rationale:

Wear shoes with rubber soles () - Quiet footwear minimizes noise disruption during sleep hours, promoting a better sleep environment.

Choice B rationale:

Conduct change of shift reports near the clients’ rooms () - Conducting reports near rooms creates noise and disrupts sleep. It’s best done in designated areas away from patients.

Choice C rationale:

Open curtains between clients in semi-private rooms () - Privacy and individual light control are crucial for sleep. Open curtains can disrupt a client’s sleep cycle.

Choice D rationale:

Turn on overhead lights briefly when checking IV lines () - Bright lights suppress melatonin production, a hormone vital for sleep. Using alternative light sources or dimmed lighting minimizes sleep disruption.

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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

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Explanation

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Correct Answer is A

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