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 D

Explanation

Atrial fibrillation is a common arrhythmia, and diuretics are often used in the management of patients with this condition to help control ﬂuid balance. However, diuretics can cause electrolyte imbalances, especially hypokalaemia (low potassium levels), which can lead to muscle cramps and other complications.

A Complete Metabolic Panel (CMP) is a blood test that measures various electrolytes, glucose, and other important components. Among the options given, the most likely lab value to be abnormal in Patient MK's case is a low level of potassium (K+), which is consistent with her symptoms and diuretic use. Option d, K+ -

1. mEq/L, is the correct option as it represents a low level of potassium, which is defined as a value less than 3.5 mEq/L.

Option a, Mg2 – 20 mEq/L, represents high magnesium levels, which are not typically associated with diuretic use or muscle cramps. Option b, Na+ - 123 mEq/L, represents low sodium levels, which are less likely to occur with diuretic use, and are typically associated with other conditions. Option c, Ca2 – 10.0 mg/dl, represents normal calcium levels and is not typically aﬀected by diuretic use.

A. Use of the incentive spirometer B. Breathing rapidly to prevent pneumonia. C. There is no need to teach the patient after surgery. D. Use of chest tube

Correct Answer is A

Explanation

The use of an incentive spirometer is essential after surgery to prevent complications such as pneumonia and atelectasis. Atelectasis is the collapse of air sacs in the lungs, which can occur after surgery due to decreased respiratory eﬀort and shallow breathing. An incentive spirometer helps the patient take deep breaths and increase their lung volume, preventing these complications.

Breathing rapidly to prevent pneumonia (option b) is not recommended as it can lead to hyperventilation and other respiratory complications.

Option c is incorrect because patient education is a crucial aspect of post-operative care, and the patient needs to be aware of the potential complications and how to prevent them.

The use of a chest tube (option d) is not usually required after hip surgery, and it is not a priority teaching for the patient.

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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

Patient MK is admited with Atrial Fibrillation an irregular heart rhythm. She is also complaining of muscle cramps to her legs and that she started a new diuretic last week. What lab value are you most likely to find on her Complete Metabolic Panel?

Correct Answer is D

Explanation

The nurse is caring for a client who recently had surgery on her left hip. What should be the priority teaching for the patient after surgery to prevent complications?

Correct Answer is A

Explanation

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