A nurse is assessing a client who is experiencing fluid volume excess. Which of the following findings should the nurse expect?
Poor skin turgor
Thready pulse
Crackles in lung bases
Flat neck veins
The Correct Answer is C
Rationale
A. Poor skin turgor: Poor skin turgor is typically a sign of fluid volume deficit, not excess. In fluid overload, the skin may appear edematous or stretched rather than dehydrated. Assessing turgor helps differentiate between dehydration and overhydration.
B. Thready pulse: A thready, weak pulse is often associated with hypovolemia due to reduced circulating volume. In fluid volume excess, pulses are usually full and bounding because of increased intravascular pressure. Pulse quality provides insight into circulatory status.
C. Crackles in lung bases: Crackles heard in the lower lung fields indicate pulmonary fluid accumulation, a common finding in fluid volume excess. Excess intravascular fluid can leak into the alveoli, causing impaired gas exchange and respiratory symptoms. Auscultation of crackles helps identify pulmonary edema early.
D. Flat neck veins: Flat neck veins are associated with low central venous pressure, typically seen in dehydration or hypovolemia. In fluid overload, neck veins are often distended due to increased venous pressure. Jugular vein assessment is a key indicator of intravascular volume status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale
A. Perform range-of-motion exercises: While exercise can promote overall health, performing range-of-motion exercises immediately before bedtime may increase alertness and stimulate the body, making it more difficult for the client to fall asleep. Exercise is better scheduled earlier in the day.
B. Offer a wet washcloth for the client to wash their face: Providing a wet washcloth allows the client to perform a relaxing bedtime hygiene routine. This can signal the body that it is time to wind down, promote comfort, and support the onset of sleep. Simple relaxation measures before bedtime are effective for managing insomnia.
C. Provide a late supper: Offering a late meal may interfere with sleep by causing digestive discomfort or increasing metabolic activity. Heavy meals close to bedtime are not recommended for clients experiencing insomnia.
D. Prepare hot cocoa or tea for the client: Beverages such as cocoa or tea often contain caffeine, which can increase alertness and worsen insomnia. Avoiding stimulants before bedtime is essential to promote restful sleep.
Correct Answer is D
Explanation
Rationale
A. Add yogurt to enteral feedings: While yogurt contains probiotics, adding it directly to enteral feedings can alter the formula’s consistency and increase the risk of tube clogging. It is not a standard intervention for diarrhea associated with enteral nutrition.
B. Change to an enteral formula that has added fiber: Formulas with added fiber are beneficial for managing chronic diarrhea or constipation, but switching formulas should be guided by the provider or dietitian rather than implemented independently.
C. Add water during tube flushes: Adding water helps maintain hydration and prevent tube clogging but does not directly address the underlying cause of diarrhea. While important for overall care, it is not the primary intervention to manage diarrhea.
D. Slow down the instillation flow rate: Rapid administration of enteral feedings can overwhelm the gastrointestinal system and contribute to diarrhea. Slowing the flow rate allows for better tolerance, reduces osmotic load, and often resolves diarrhea associated with high-volume or fast feedings.
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