A client admited with heart failure requires careful monitoring of his ﬂuid status. Which method will provide the nurse with the best indication of the client’s ﬂuid status?

daily electrolyte monitoring

daily weights

output measurements

daily BUN and serum creatinine monitoring

Answer and Explanation

The Correct Answer is B

Fluid retention is a common complication in heart failure, and monitoring the client's ﬂuid status is crucial to manage the condition eﬀectively. Daily weights are an essential component of monitoring ﬂuid status and are the most sensitive and practical method to detect changes in the client's ﬂuid status. Weight gain is a reliable indicator of ﬂuid retention, and even small increases in weight can indicate the need for changes in the client's treatment plan.

Although electrolyte monitoring (option a), output measurements (option c), and daily BUN and serum creatinine monitoring (option d) can provide valuable information about the client's ﬂuid status, they are not as sensitive or practical as daily weights. Electrolyte monitoring can help detect changes in ﬂuid balance, but it does not provide a direct indication of ﬂuid status. Output measurements can indicate ﬂuid loss, but they do not provide an accurate assessment of ﬂuid retention. BUN and serum creatinine monitoring can detect changes in renal function, but they are not specific to ﬂuid status.

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Correct Answer is B

Explanation

Hypertonic solutions have a higher concentration of solutes (such as sodium, glucose, or mannitol) than the ﬂuid in the body's cells, causing water to move out of the cells and into the bloodstream. This results in the shrinking of the cells and an increase in extracellular ﬂuid volume.

Examples of hypertonic solutions include 10% dextrose in water (D10W), 3% saline, and 5% dextrose in 0.9% saline.

In contrast, isotonic solutions have the same concentration of solutes as the ﬂuid in the body's cells, and hypotonic solutions have a lower concentration of solutes than the ﬂuid in the body's cells.

Therefore, in this scenario, the nurse should administer a hypertonic solution to the client who requires IV ﬂuids.

A. Obtaining arterial blood gases B. Giving IV epinephrine C. Initiating CPR D. Intubating the patient

Correct Answer is C

Explanation

CPR (Cardiopulmonary Resuscitation) is a life-saving procedure that is performed when a person's heart has stopped beating. It involves chest compressions and rescue breathing to restore the circulation of oxygenated blood to the brain and other vital organs. The timely initiation of CPR can significantly increase the chances of a patient's survival.

In a healthcare setting, UAPs/CNAs are often trained to provide basic life support, including initiating CPR, until a healthcare provider arrives. However, giving IV epinephrine, intubating the patient, and obtaining arterial blood gases are all advanced medical procedures that require specialized training and expertise. These actions should only be performed by trained healthcare providers, such as registered nurses, physicians, or respiratory therapists, and cannot be delegated to UAPs/CNAs.

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A client admited with heart failure requires careful monitoring of his ﬂuid status. Which method will provide the nurse with the best indication of the client’s ﬂuid status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Explanation

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