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

Choice A reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Three defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

Choice B reason: This is correct because it shows that the PN is familiar with the nursing diagnosis criteria. One defining characteristic is the least number required for the diagnosis of Impaired Verbal Communication, according to the NANDA-I taxonomy.

Choice C reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Four defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

Choice D reason: This is incorrect because it shows that the PN is not familiar with the nursing diagnosis criteria. Two defining characteristics are not the least number required for the diagnosis of Impaired Verbal Communication.

A. Crackles to Bilateral lobes B. Tenting skin and wet mucous membranes C. C Tachycardia and hypotension D. +4 edema to bilateral lower extremities and confusion

Correct Answer is C

Explanation

Dehydration can cause a decrease in blood volume, leading to a drop in blood pressure (hypotension) and an increase in heart rate (tachycardia) as the body tries to compensate. Tenting skin and dry mucous membranes are also signs of dehydration, but wet mucous membranes are not. Crackles in the lungs, edema, and confusion can occur with ﬂuid overload, but not with dehydration.

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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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Correct Answer is C

Explanation

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