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
Crackles heard in the lungs
Decreased skin turgor
The Correct Answer is C
Fluid overload refers to an excess volume of fluid in the body, which can occur as a result of various factors, including excessive fluid intake or inadequate fluid removal. Crackles heard in the lungs, also known as rales, can indicate fluid accumulation in the lungs, a condition known as pulmonary edema. It is a common manifestation of fluid overload and can be detected through auscultation of the lungs.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Wearing shoes with rubber soles can minimize noise and provide a quieter environment for the clients. It helps reduce disruptions caused by footsteps, especially during nighttime when clients are trying to sleep.
Conducting change-of-shift report near the clients' rooms can lead to increased noise levels and disturb clients' sleep. It is best to conduct report in a designated area away from patient rooms to minimize disruptions.
Overhead lights should be avoided during nighttime or sleep hours as they are bright and can disrupt a client's sleep. Instead, nurses should use a low-intensity light or a flashlight to check IV lines or attend to other needs. This helps minimize disruptions to the client's rest.
Opening curtains between clients in semiprivate rooms can compromise privacy and contribute to increased noise levels. It is important to provide privacy for clients, especially during their rest periods.
Correct Answer is C
Explanation
Assessing the client's suicidal intent and the presence of a specific plan for self-harm is crucial in determining the level of immediate risk and the need for intervention. This question directly addresses the client's current state and potential danger.
While all the questions are important in assessing the client's situation, determining the presence of a plan for self-harm takes precedence as it helps evaluate the level of imminent danger and the need for immediate intervention.
The other questions are also important but can be addressed after ensuring the client's safety and appropriate intervention based on the information gathered regarding the plan for self-harm. These questions can provide additional information to further assess the client's support system, history, and current stressors, which can contribute to understanding the context and potential risk factors for the client.
Remember, if the client expresses an immediate plan and intent for self-harm, it is essential to take appropriate steps to ensure their safety, such as involving the appropriate mental health professionals, implementing a safety plan, and providing constant supervision as needed.
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