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
Explanation:
Bleach is an effective disinfectant for blood spills and is recommended by healthcare guidelines for its ability to kill a broad range of microorganisms, including bloodborne pathogens such as human immunodeficiency virus (HIV). To prepare a bleach solution, the nurse can mix 1-part bleach with 10 parts water. This diluted bleach solution can be used to clean and disinfect the overbed table surfaces that have been contaminated with blood.
A- Chlorhexidine is an antiseptic commonly used for skin preparation before invasive procedures, but it is not the ideal choice for disinfecting surfaces or objects after a blood spill.
B- Isopropyl alcohol is effective for disinfecting small surfaces, but it may not be as effective as bleach for blood spills, particularly in the context of bloodborne pathogens like HIV.
D- Hydrogen peroxide can be used as a disinfectant, but it may not be as effective as bleach in eliminating bloodborne pathogens from surfaces.
Correct Answer is C
Explanation
A.This is incorrect because suction should not be applied during the insertion of the catheter. Suctioning should only be applied while withdrawing the catheter to avoid causing trauma to the mucosa.
B. Suctioning should generally be performed for no longer than 10 seconds at a time to minimize the risk of complications such as hypoxia.
C.This response is correct because waiting approximately 1 minute between suctioning attempts allows the client time to recover and reoxygenate. This interval helps prevent hypoxia and mucosal damage, which are important considerations during the suctioning process.
D.In adults insert catheter approximately 16 cm (6.5 inches); in older children, 8– 12 cm (3–5 inches); in infants and young children, 4–7.5 cm (1.5–3 inches). Rule of thumb is to insert catheter distance from tip of nose (or mouth) to angle of mandible.
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