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 are not typically indicative of fluid overload. They may suggest decreased gastrointestinal motility, but this finding alone does not specifically indicate fluid overload.
B. Bradycardia is not typically associated with fluid overload. Instead, tachycardia may occur as the body attempts to compensate for decreased cardiac output.
C. Hypotension may occur with fluid overload in severe cases, but it is not a consistent or specific finding. Other signs, such as bounding pulses, are more indicative of fluid overload.
D. Bounding pulses, or strong and forceful arterial pulses, can be a sign of fluid overload due to increased blood volume. This finding may be observed in clients receiving excessive enteral feedings or intravenous fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Brushing teeth immediately after eating may exacerbate nausea, especially if the client is experiencing pregnancy-related nausea and vomiting.
B. Laying down for 30 minutes after meals may worsen nausea and reflux symptoms.
C. Drinking 12 oz of water with each meal may contribute to feelings of fullness and exacerbate nausea and vomiting.
D. Eating a dry carbohydrate before getting out of bed, such as crackers or dry toast, can help alleviate nausea and vomiting associated with pregnancy by providing a bland, easily digestible source of energy before the client starts moving in the morning.
Correct Answer is C
Explanation
A. Decreased serum osmolarity: Fluid volume deficit typically leads to an increase in serum osmolarity due to concentration of solutes in the blood, not a decrease.
B. Decreased hematocrit: Dehydration causes hemoconcentration, leading to an increase in hematocrit, not a decrease.
C. Elevated blood urea nitrogen (BUN): Dehydration results in decreased renal perfusion and concentration of urea in the blood, leading to elevated BUN levels.
D. Lower urine specific gravity: Dehydration causes increased urine concentration, resulting in higher urine specific gravity, not lower.
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