A client with fluid overload receives a prescription for fluid restriction of 1 liter/day and a diuretic. Which action(s) should the nurse perform to best evaluate the effectiveness of the treatment? Select all that apply.
Calculate the intake and output.
Assess pulse rate.
Monitor the temperature.
Checking for orthostatic hypotension.
Obtain a daily weight.
Correct Answer : A,E
A. Calculate the intake and output: Measuring intake and output directly reflects fluid balance, making it one of the most reliable ways to determine if fluid restriction and diuretics are effective. Tracking fluid intake compared to urine output helps assess reduction in fluid overload.
B. Assess pulse rate: While monitoring pulse rate is part of routine assessment, it does not provide a clear picture of whether fluid overload is improving. Changes in pulse may occur with dehydration, arrhythmias, or other conditions, but it is not a primary measure of fluid balance.
C. Monitor the temperature: Body temperature is important for identifying infection or inflammation but does not indicate fluid status. Monitoring temperature would not help evaluate whether fluid restriction and diuretic therapy are relieving fluid overload.
D. Checking for orthostatic hypotension: Orthostatic changes can suggest hypovolemia or dehydration but are less useful for measuring the gradual effectiveness of fluid restriction. They may be monitored if over-diuresis is suspected, but they are not the best evaluation tool.
E. Obtain a daily weight: Daily weight is one of the most accurate indicators of fluid balance. A decrease in weight reflects effective removal of excess fluid, as even small weight changes can indicate significant fluid gain or loss in the body.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Total volume = 100 mL.
Infusion time = 30 minutes
Infusion time = 30 minutes / 60 minutes/hour
= 0.5 hours.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Total time (hr)
= 100 mL / 0.5 hr
= 200 mL/hr.
Correct Answer is D
Explanation
A. Noncompliance with treatment regimen: While noncompliance can affect recovery, it is secondary to the immediate physiological risks posed by malnutrition. Addressing noncompliance becomes relevant after stabilizing the client’s health.
B. Disturbed Body Image: Distorted body image is a core psychological issue in anorexia nervosa, but it does not pose an immediate threat to the client’s life. Interventions targeting body image are important but not the first priority.
C. Interrupted Family Processes: Family dynamics may influence the client’s condition and recovery, yet they are not life-threatening. Family interventions are supportive and adjunctive to stabilizing the client’s nutritional status.
D. Imbalanced Nutrition: less than body requirements: Malnutrition directly threatens the adolescent’s physiological stability, affecting cardiovascular, gastrointestinal, and endocrine function. Correcting nutritional deficits and preventing complications such as electrolyte imbalance or organ failure is the highest priority in care planning.
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