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
Crackles heard in the lungs
Decreased skin turgor
The Correct Answer is C
Fluid overload refers to an excess volume of fluid in the body, which can occur as a result of various factors, including excessive fluid intake or inadequate fluid removal. Crackles heard in the lungs, also known as rales, can indicate fluid accumulation in the lungs, a condition known as pulmonary edema. It is a common manifestation of fluid overload and can be detected through auscultation of the lungs.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
Weight loss is typically associated with inadequate calorie or nutrient intake, rather than fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C"]
Explanation
A: The tubing should not be coiled on the bed, especially not above the collection bag, as this can interfere with the drainage of urine and increase the risk of infection.
B: The drainage bag should always be kept below the level of the bladder during ambulation to prevent backflow and reduce the risk of infection.
C: Securing the catheter tubing to the lower abdomen (for male clients) or thigh (for female clients) helps to reduce the risk of catheter displacement and trauma. Proper securing also prevents unnecessary tension on the tubing, which can cause urethral irritation.
D:A sterile specimen should be collected from the sampling port of the catheter tubing, not directly from the drainage bag, which could lead to contamination.
Correct Answer is A
Explanation
A.Using visual aids such as pictures, diagrams, or translation cards can help bridge the communication gap between the nurse and the client. This approach ensures better understanding and reduces miscommunication, especially when discussing procedures, medications, or discharge instructions.
B.This is not appropriate because family members may misinterpret medical information, omit details, or add their own opinions. A trained medical interpreter should be used to ensure accurate and confidential communication.
C. Speaking to the client at an increased volume in is not an effective solution for a language barrier. Simply speaking louder will not address the issue of language comprehension. It is important to use appropriate communication strategies, such as seeking a qualified interpreter or using visual aids or gestures to facilitate understanding.
D. Assuming that the client nodding indicates an understanding of the information in is not reliable. Nodding can have different cultural interpretations and may not always indicate comprehension. It is important to use other means of communication to confirm understanding, such as using a professional interpreter or utilizing visual aids.
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