A client reports weakness, dizziness, nausea and vomiting that has lasted for three days. The nurse's assessment reveals dry tongue and oral mucosa, and dark concentrated urine. Which additional assessment would best evaluate the client's fluid status?

Respiratory rate and depth

Rectal temperature

Blood pressure lying, sitting and standing

Pulse oximetry reading at rest

Answer and Explanation

The Correct Answer is C

Choice A reason: This is not the best answer. Respiratory rate and depth can indicate the client's oxygenation and ventilation, but not necessarily their fluid status. The client may have normal or increased respiratory rate and depth due to dehydration, acidosis, or anxiety, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's respiratory rate and depth, but also assess other parameters of fluid status.

Choice B reason: This is not the best answer. Rectal temperature can indicate the client's core body temperature, but not necessarily their fluid status. The client may have normal or elevated rectal temperature due to infection, inflammation, or dehydration, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's rectal temperature, but also assess other parameters of fluid status.

Choice C reason: This is the best answer. Blood pressure lying, sitting and standing can indicate the client's fluid status and vascular tone. The client may have low blood pressure due to fluid loss, hypovolemia, or vasodilation, and this can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. The nurse should measure the client's blood pressure in different positions and observe for signs of orthostatic hypotension, such as dizziness, fainting, or blurred vision.

Choice D reason: This is not the best answer. Pulse oximetry reading at rest can indicate the client's oxygen saturation, but not necessarily their fluid status. The client may have normal or decreased pulse oximetry reading due to hypoxia, anemia, or poor peripheral perfusion, but this does not reflect their fluid volume or distribution. The nurse should monitor the client's pulse oximetry reading, but also assess other parameters of fluid status.

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Correct Answer is D

Explanation

Choice A reason: I should continue to read the labels of foods I select at the grocery store is not a statement that indicates a need for further clarification by the nurse. This statement shows that the client understands the importance of choosing foods that are low in sodium, fat, and calories, which can help lower blood pressure and prevent complications.

Choice B reason: Keeping my blood pressure under control reduces my risk for a heart attack is not a statement that indicates a need for further clarification by the nurse. This statement shows that the client understands the benefits of pharmacologic therapy for hypertension, which can prevent or delay the development of cardiovascular disease.

Choice C reason: When I get out of bed in the morning, I should first sit for a few minutes and then stand is not a statement that indicates a need for further clarification by the nurse. This statement shows that the client understands how to prevent or minimize orthostatic hypotension, which is a possible side effect of some anti-hypertensive medications.

Choice D reason: I will be able to stop my anti-hypertensive medication when my blood pressure is normal is a statement that indicates a need for further clarification by the nurse. This statement shows that the client has a misconception about the nature and duration of pharmacologic therapy for hypertension. The nurse should explain that hypertension is a chronic condition that requires lifelong treatment and monitoring, and that stopping the medication abruptly can cause a rebound increase in blood pressure and increase the risk of complications.

A. Perform daily weights. B. Take the blood pressure. C. Auscultate breath sounds. D. Measure urinary output.

Correct Answer is A

Explanation

Choice A reason: Performing daily weights is the best method to evaluate the client's response to furosemide, a drug that reduces fluid retention and swelling by increasing the urine output. ¹ Daily weights can help monitor the changes in the client's fluid status and the effectiveness of the drug. The nurse should weigh the client at the same time each day, using the same scale and clothing.

Choice B reason: Taking the blood pressure is not the best method to evaluate the client's response to furosemide. Furosemide can also lower the blood pressure by reducing the volume of fluid in the blood vessels. ¹ However, blood pressure can be influenced by many other factors, such as heart rate, stress, or medications. Blood pressure is not a reliable indicator of the client's fluid status or the effectiveness of the drug.

Choice C reason: Auscultating breath sounds is not the best method to evaluate the client's response to furosemide. Furosemide can help improve the breath sounds by reducing the fluid accumulation in the lungs, which can cause shortness of breath or crackles. ¹ However, breath sounds can also be affected by other factors, such as lung infections, asthma, or allergies. Breath sounds are not a reliable indicator of the client's fluid status or the effectiveness of the drug.

Choice D reason: Measuring urinary output is not the best method to evaluate the client's response to furosemide. Furosemide can increase the urinary output by stimulating the kidneys to excrete more water and electrolytes. ¹ However, urinary output can also vary depending on the fluid intake, kidney function, or other medications. Urinary output is not a reliable indicator of the client's fluid status or the effectiveness of the drug.

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A client reports weakness, dizziness, nausea and vomiting that has lasted for three days. The nurse's assessment reveals dry tongue and oral mucosa, and dark concentrated urine. Which additional assessment would best evaluate the client's fluid status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement, made by a client receiving pharmacologic therapy for hypertension, indicates a need for further clarification by the nurse?

Correct Answer is D

Explanation

The client has been prescribed furosemide 40 mg IV to treat peripheral edema. Which method should the nurse use to best evaluate the client's response to this medication?

Correct Answer is A

Explanation

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