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 C
Explanation
a.Applying the restraint under the client's clothes: Restraints should be applied over the client's clothes to avoid direct skin contact and reduce the risk of skin irritation or injury.
b.Tying the restraint to the railing of the client's bed: Restraints should not be tied to bed rails or any other fixed objects. This can increase the risk of injury to the client and should be avoided.
c.Placing the client in a sitting position is appropriate when applying a belt restraint, as it helps prevent respiratory compromise and allows the client to maintain a safer and more comfortable posture.
d.A belt restraint should be placed around the client's waist, not across the chest, to avoid restricting breathing.
Correct Answer is B
Explanation
Veracity refers to the principle of truthfulness and honesty in communication. By truthfully communicating about the adverse effects of the prescribed medications, the nurse is demonstrating veracity. This ethical principle emphasizes the importance of providing accurate information to the client to promote informed decision-making and autonomy.
Justice refers to fairness and equitable treatment, ensuring that individuals receive what they are due and that resources are distributed appropriately. While justice is an important ethical concept in healthcare, it is not directly applicable to the nurse's communication about adverse effects.
Autonomy refers to respecting the right of individuals to make their own decisions and choices regarding their healthcare. While truthfully communicating about adverse effects supports autonomy, autonomy itself is not the specific ethical concept being exhibited in this scenario. Beneficence refers to the ethical principle of acting in the best interest of the client and promoting their well-being. While providing accurate information about adverse effects can be seen as a form of beneficence, it does not directly address the nurse's truthful communication in this specific scenario.
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