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. A blood glucose level of 120 mg/dL is within the expected range for a client receiving total parenteral nutrition and does not require immediate intervention.
B. A serum sodium level of 138 mEq/L is within the normal range and does not require immediate intervention.
C. An oral temperature of 37.6°C (99.7°F) is slightly elevated but may be within the client's normal range and does not require immediate intervention unless accompanied by other signs of infection.
D. A weight increase of 2 kg (4.4 lb) in the past 24 hours indicates fluid overload, which can lead to complications such as heart failure or pulmonary edema. Immediate intervention, such as adjusting the rate of fluid administration or notifying the healthcare provider, is necessary to prevent further complications.
Correct Answer is D
Explanation
A. Insisting the client use direct eye contact may be intimidating or uncomfortable for the client, especially in a mental health setting where individuals may have varying levels of comfort with eye contact.
B. Seating the client at such a distance may create a physical barrier and hinder effective communication between the nurse and the client.
C. Positioning the client's chair between the nurse's chair and the door may make the client feel trapped or uncomfortable, especially during a sensitive interview.
D. Leaning in slightly when speaking to the client demonstrates attentiveness and facilitates a sense of closeness and engagement in the conversation, which can help build rapport and trust.
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