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 B

Explanation

A. Incorrect. While a client scheduled for surgery is important, addressing the client with elevated blood pressure and a headache takes priority.
B. Correct. The client with elevated blood pressure and a headache requires immediate assessment, as these symptoms could indicate a hypertensive crisis or other serious complications.
C. Incorrect. While addressing postoperative nausea is important, the client with elevated blood pressure and headache requires more immediate attention.
D. Incorrect. A client with a Jackson Pratt drain may need care and assessment, but a client with elevated blood pressure and a headache has a more urgent need for evaluation.

A. "I will wash my baby's head using a moist towelette." B. "I will wash my baby's face with a warm, wet washcloth without soap." C. "I will bathe my baby under a faucet of running water." D. "I will give my baby a bath every day."

Correct Answer is B

Explanation

A. Incorrect. Newborns' heads can be sensitive, and washing with a moist towelette might not be gentle enough for their delicate skin.
B. Correct. Newborns' skin is sensitive, and using a warm, wet washcloth without soap is recommended to gently clean their face.
C. Incorrect. Bathing a newborn under a running faucet can be challenging and might expose the baby to temperature variations. It's important to ensure that the baby is comfortable during bathing.
D. Incorrect. Newborns don't need to be bathed daily. Bathing them too frequently can dry out their skin and lead to discomfort.

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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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