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

Bradycardia

Oliguria

Peripheral edema

Hypotension

Answer and Explanation

The Correct Answer is C

A. Bradycardia:
Explanation: Bradycardia refers to a slow heart rate. In hypervolemia (fluid overload), the heart often compensates by increasing the heart rate rather than causing bradycardia.

B. Oliguria:
Explanation: Oliguria refers to decreased urine output. In hypervolemia, the increased fluid volume can lead to increased urine output rather than oliguria.

C. Peripheral Edema:
Explanation: Peripheral edema, or swelling in the extremities, is a common manifestation of hypervolemia. Excess fluid can accumulate in the tissues.

D. Hypotension:
Explanation: Hypertension, not hypotension, is more commonly associated with hypervolemia. The increased volume of fluid in the blood vessels can lead to elevated blood pressure.

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Correct Answer is C

Explanation

A. Fluid volume overload:
Explanation: Fluid volume overload is not typically associated with urinary incontinence. It is more commonly linked to conditions affecting the heart and kidneys.

B. Kidney stones:
Explanation: Kidney stones are not directly related to urinary incontinence. Kidney stones may cause pain, hematuria (blood in urine), and changes in urinary frequency.

C. Dermatitis:
Explanation: This is correct. Urinary incontinence can lead to skin irritation and dermatitis, especially if the skin is constantly exposed to urine. Keeping the perineal area clean and dry is important to prevent dermatitis.

D. Hypoglycemia:
Explanation: Hypoglycemia is not typically associated with urinary incontinence. It is more related to low blood sugar levels and is not a direct consequence of urinary incontinence.

A. Check the gastric residual every 8 hr. B. Change the feeding bag every 24 hr. C. Flush the tube with sterile sodium chloride solution every 2 hr. D. Position the head of the client's bed at 15.

Correct Answer is ["B"]

Explanation

Correct answer: B

A. Check the gastric residual every 8 hr:
Explanation:It is generally recommended to check gastric residuals more frequently than every 8 hours, often every 4-6 hours, especially in the initial stages of continuous enteral feedings, to monitor tolerance and prevent complications such as aspiration.

B. Change the feeding bag every 24 hr:
Explanation: Changing the feeding bag and tubing at regular intervals helps prevent bacterial contamination and maintain aseptic technique. The frequency of bag changes is typically scheduled every 24 hours or according to facility protocols.

C. Flush the tube with sterile sodium chloride solution every 2 hr:
Explanation:While it is important to flush the feeding tube regularly to maintain patency, using sterile water is typically recommended unless there is a specific clinical indication for sterile sodium chloride. The frequency of flushing (usually every 4-6 hours for continuous feeding) should be determined based on the institution's protocol and the client's specific needs.

D. Position the head of the client's bed at 15 degrees:
Explanation:To reduce the risk of aspiration, the head of the bed should be elevated to at least 30-45 degrees during enteral feedings, not just 15 degrees. Elevating the head of the bed helps prevent reflux and aspiration.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has urinary incontinence. The nurse recommends monitoring the client for which of the following findings?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client prescribed continuous enteral feedings. Which of the following actions should the nurse plan to take?

Correct Answer is ["B"]

Explanation

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