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 C
Explanation
A. Water intoxication can lead to dilutional hyponatremia, which may result in fluid shifting into cells, causing cellular swelling and potentially cerebral edema, but generalized edema is not typically associated with water intoxication.
B. Water intoxication leads to dilution of electrolytes, including sodium, which results in decreased urine specific gravity rather than elevated.
C. Thready pulse is a common finding in water intoxication due to electrolyte imbalances and hemodilution.
D. Increased hematocrit is not typically associated with water intoxication; rather, it may indicate dehydration or hemoconcentration.
Correct Answer is C
Explanation
A. "Limit your meals to three times per day." - Incorrect. Following gastric bypass surgery,
clients are typically advised to eat small, frequent meals rather than limiting to three large meals per day.
B. "Consume at least 25 grams of fiber daily." - Incorrect. While fiber is important for gastrointestinal health, clients following gastric bypass surgery may need to avoid high-fiber foods initially and gradually reintroduce them based on individual tolerance.
C. "Start each meal with a protein source." - Correct. Protein is essential for wound healing and maintenance of muscle mass after gastric bypass surgery. Starting each meal with a protein source helps ensure an adequate intake.
D. "Check your blood glucose level before each meal." - This instruction is not directly related to dietary management following gastric bypass surgery. Blood glucose monitoring may be necessary for clients with diabetes, but it is not specific to post-gastric bypass dietary
instructions.
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