A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?
Weight loss
Decreased blood pressure
Decreased skin turgor
Crackles heard in the lungs
The Correct Answer is D
A. Incorrect. Weight loss is not a manifestation of fluid overload but rather of insufficient nutrition.
B. Incorrect. Decreased blood pressure is not a manifestation of fluid overload but could indicate hypovolemia.
C. Incorrect. Decreased skin turgor is a sign of dehydration, not fluid overload.
D. Correct. Crackles heard in the lungs can indicate fluid overload in the lungs, also known as pulmonary edema. This is often caused by an excess of fluid in the body.
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Related Questions
Correct Answer is C
Explanation
A. Incorrect. Irrigation of a wound with antibiotic solution typically does not require informed consent.
B. Incorrect. Insertion of a nasogastric tube does not usually require informed consent unless it involves specific risks or is part of a research protocol.
C. Correct. Placement of a central venous catheter is an invasive procedure that involves risks, and informed consent is usually required.
D. Incorrect. Administration of an iron injection using the Z-track technique is a routine procedure and does not usually require informed consent.
Correct Answer is B
Explanation
The correct answer is choiceb. Support the client’s decision to stop the treatment.
Choice A rationale:
While discussing the decision with family can be important, the nurse’s primary responsibility is to respect and support the client’s autonomy and decision-making capacity. Encouraging the client to discuss with family is secondary to supporting their decision.
Choice B rationale:
Supporting the client’s decision to stop treatment respects their autonomy and right to make decisions about their own care.This is a fundamental principle in nursing ethics and patient-centered care.
Choice C rationale:
Discussing alternative treatment methods may be appropriate in some contexts, but in this case, the client has already made a decision to stop dialysis. The nurse should focus on supporting this decision rather than suggesting alternatives.
Choice D rationale:
Asking the facility chaplain to visit the client can be supportive, but it should not be the nurse’s primary action. The nurse should first support the client’s decision and then offer additional support services as needed.
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