A nurse is assessing a client who is receiving enteral feedings via a gastrostomy tube. The nurse should identify that which of the following findings indicates fluid overload?
Diminished bowel sounds
Bradycardia
Hypotension
Bounding pulses
The Correct Answer is D
A. Diminished bowel sounds: Diminished bowel sounds indicate decreased gastrointestinal motility or possible ileus, but they are not a sign of fluid overload. This finding is unrelated to the client’s fluid status.
B. Bradycardia: Bradycardia refers to a slow heart rate, which is more often associated with conduction abnormalities, medications, or vagal stimulation. It does not typically indicate fluid overload.
C. Hypotension: Hypotension usually reflects fluid deficit, blood loss, or cardiovascular compromise. Fluid overload is more likely to cause hypertension rather than low blood pressure.
D. Bounding pulses: Bounding pulses are a classic cardiovascular manifestation of fluid overload. Excess intravascular volume increases stroke volume and arterial pressure, resulting in strong, forceful pulses, making this an important sign for the nurse to recognize.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Serum albumin: Albumin levels reflect nutritional status and liver function, not the effectiveness of allopurinol. Monitoring albumin is not relevant for assessing the drug’s impact on uric acid.
B. Magnesium level: Magnesium levels are not affected by allopurinol and do not indicate therapeutic effectiveness. Routine monitoring of magnesium is not necessary for clients taking this medication.
C. Serum chloride: Chloride is an electrolyte involved in acid-base balance and does not reflect allopurinol efficacy. Changes in chloride levels are unrelated to uric acid management.
D. Uric acid level: Allopurinol is a xanthine oxidase inhibitor that reduces uric acid production. Monitoring serum uric acid levels allows the nurse to determine whether the medication effectively lowers uric acid and helps prevent gout flares or uric acid nephropathy.
Correct Answer is B
Explanation
A. INR 1.1 (0.8 to 1.1): A normal INR indicates proper clotting function and does not increase risk for delayed wound healing. Coagulation status is adequate to support post-surgical recovery.
B. Hyperemesis: Persistent vomiting can lead to fluid and electrolyte imbalances, malnutrition, and protein depletion, all of which impair wound healing. Adequate nutrition is critical for collagen synthesis and tissue repair after surgery.
C. HbA1c 5.6% (4 to 5.9%): A normal HbA1c indicates good blood glucose control, which supports wound healing. Elevated blood glucose can impair healing, but this client’s level is within normal limits.
D. Uncontrolled pain: While uncontrolled pain can affect mobility and stress responses, it does not directly impair the physiological processes of wound healing. Pain management is important but less directly linked to delayed tissue repair than nutritional deficits.
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