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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. Memory loss that disrupts ADLs is a characteristic feature of dementia.
B. Acute onset of confusion might be related to delirium rather than dementia.
C. Catatonia is not a typical finding in dementia.
D. Illusions are not commonly associated with dementia.
Correct Answer is D
Explanation
A. Droplet precautions are not indicated for HIV; standard precautions should be followed.
B. Granulocyte colony-stimulating factor is typically used to increase white blood cell production and is not directly related to HIV care.
C. Exchange transfusions are not a routine intervention for infants with HIV.
D. Correct. Monitoring the infant's lymphocyte count is important to assess immune function and response to HIV treatment.
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