Nokea
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?
- A. Decreased blood pressure
- B. Decreased skin turgor
- C. Weight loss
- D. Crackles heard in the lungs
Correct Answer: D
Rationale: Crackles in the lungs indicate fluid overload from excessive enteral feeding.
You may also like to solve these questions
A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?
- A. Memory loss that disrupts ADLs
- B. Acute onset of confusion
- C. Illusions
- D. Catatonia
Correct Answer: A
Rationale: Memory loss disrupting ADLs is a hallmark of dementia.
A nurse is supervising an assistive personnel (AP) who is applying antiembolic stockings for a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Asking the client to point their toes before applying the stockings
- B. Ensuring that creases in the stockings are on the front of the client's legs
- C. Turning the stockings inside out before applying them
- D. Applying the stockings before the client gets out of bed
Correct Answer: B
Rationale: Creases should be avoided to prevent skin irritation; this requires intervention.
A nurse is reinforcing teaching about the side effects of metoprolol. Which of the following client statements indicates an understanding of the teaching?
- A. I need to be careful when standing up from bed.
- B. I should limit my intake of leafy green vegetables.
- C. I should expect some weight loss.
- D. I may experience loss of taste.
Correct Answer: A
Rationale: Metoprolol can cause orthostatic hypotension, requiring caution when standing.
The child has asthma.
A nurse is reinforcing teaching with a parent of a child who has asthma about the administration of montelukast. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will give this medication to my child every 2 hours if he is wheezing.
- B. I will give this medication to my child once daily in the evening.
- C. I can stop giving my child this medication if he is taking a steroid.
- D. It takes 2 months of scheduled use before this medication is effective.
Correct Answer: B
Rationale: Montelukast is taken once daily in the evening for asthma prevention.
A nurse is assisting with the care of a group of clients during a mass casualty event. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
- A. Respond to family members about a client's condition.
- B. Determine which clients should be seen first.
- C. Clean and dress client abdominal wounds.
- D. Take vital signs on clients as they are admitted.
Correct Answer: D
Rationale: Taking vital signs is within the AP's scope, unlike triage or wound care.