A nurse is collecting data on a client who is experiencing hypervolemia. Which of the following findings should the nurse expect?

A. To confirm the placement of the NG tube:
Confirming NG tube placement is typically done using other methods, such as auscultation of air insufflation, pH testing, or X-ray. Gastric residual measurement helps assess the status of the stomach content but is not the primary method for confirming tube placement.

B. To determine the client's electrolyte balance:
While the gastric contents do contain electrolytes, the primary purpose of measuring gastric residual is to assess gastric emptying and potential feeding intolerance. It is not the most accurate method for determining overall electrolyte balance.

C. To identify delayed gastric emptying:
This is the correct and primary purpose. Measuring gastric residual helps in identifying if there's a delay in the stomach emptying the previously administered feeding, which can inform the nurse about the client's tolerance to enteral nutrition.

D. To remove gastric acid that might cause dyspepsia:
The process of measuring gastric residual doesn't involve removing gastric acid. It's more about assessing how much of the previously administered feeding remains in the stomach. If there's a high residual volume, it may suggest delayed emptying or feeding intolerance. The focus is on adjusting the feeding plan rather than removing gastric acid.

A. Moist skin: Dehydration often leads to dry skin rather than moist skin. When the body is dehydrated, it conserves water, and one of the signs can be dry, less elastic skin.

B. High blood pressure: Dehydration tends to result in lower blood volume, which can lead to lower blood pressure rather than high blood pressure. However, severe dehydration may cause a drop in blood pressure.

C. Dark-colored urine: Dehydration commonly causes urine to become more concentrated, leading to darker urine. This is due to the kidneys conserving water and producing less urine.

D. Distended neck veins: Dehydration is more likely to result in decreased blood volume and lower venous return, which would not typically lead to distended neck veins. Distended neck veins are more commonly associated with conditions like heart failure.