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 B
Explanation
A. Incorrect. This may come across as confrontational and defensive.
B. Correct. This response opens communication and shows respect for the client's concerns.
C. Incorrect. This response could be perceived as manipulative and unhelpful.
D. Incorrect. This response may create fear and resistance rather than addressing the client's concerns.
Correct Answer is A
Explanation
A. Correct. Assessing whether the client has a plan for self-harm is a priority in evaluating the immediate risk of suicide. If a plan is present, further assessment and intervention are needed.
B. Incorrect. While having support is important, knowing whether the client has a plan for self-harm takes precedence.
C. Incorrect. While a family history of suicide is a risk factor, it is not as immediate a concern as determining whether the client has a current plan.
D. Incorrect. Assessing the sources of stress is important, but the immediate risk of self-harm takes priority.
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