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.

Answer and Explanation

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.

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Correct Answer is ["A","D","E"]

Explanation

A. Thirst: Recurrent yeast infections in adolescents may indicate underlying hyperglycemia, as excessive glucose in the urine promotes fungal growth. Thirst is a classic symptom of diabetes mellitus and should be assessed.

B. Increased appetite: While diabetes can sometimes cause polyphagia, it is less specific than other signs such as thirst, urinary frequency, and tachycardia. It may not be present in every case and is not a primary screening indicator.

C. Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism, not recurrent yeast infections. Assessing for this symptom is not directly relevant to evaluating potential diabetes in this adolescent.

D. Tachycardia: Elevated heart rate can occur with dehydration caused by hyperglycemia and osmotic diuresis. Tachycardia may be an important clinical clue in assessing for undiagnosed diabetes.

E. Urinary frequency: Polyuria is a hallmark symptom of hyperglycemia and diabetes mellitus. Recurrent yeast infections may prompt assessment for urinary frequency as part of the screening for possible diabetes.

A. Drinking grapefruit juice will reduce the effects of the medication. B. If I experience any difficulty with breathing I will report it. C. Monitoring for changes in stool color is important. D. I should take the medication with antacids.

Correct Answer is D

Explanation

A. Drinking grapefruit juice will reduce the effects of the medication: Grapefruit juice can interact with itraconazole, but it typically increases rather than reduces drug levels. The client’s awareness of potential interactions is important, though clarification may be needed.

B. If I experience any difficulty with breathing I will report it: Respiratory symptoms could indicate an allergic reaction or adverse effect; reporting these promptly is appropriate and demonstrates understanding.

C. Monitoring for changes in stool color is important: Itraconazole can affect liver function, and changes in stool or urine may signal hepatotoxicity. Monitoring these changes is appropriate teaching.

D. I should take the medication with antacids: Antacids reduce gastric acidity, which decreases itraconazole absorption and effectiveness. The client should be instructed to avoid antacids around the time of medication administration.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 14-year-old girl presents to the school nurse with the fourth vaginal yeast infection she has had during the past 6 months. The nurse should assess the adolescent for which finding(s)? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

A client receives a prescription for itraconazole. Which statement made by the client requires additional instruction by the nurse?

Correct Answer is D

Explanation

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