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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["0.6"]

Explanation

Calculation:

Convert the client's weight from pounds (lb) to kilograms (kg).

The client's weight is 154 lb.

Client weight (kg) = 154lb/2.2lb/kg

= 70kg.

Calculate the total dose to be administered (units).

The ordered dose is 200 units/kg.

Total dose (units) = 200units/kg×70kg

= 14,000units.

Calculate the volume to administer in milliliters (mL).

Available concentration is 25,000units/mL.

Volume (mL) = Totaldose(units)/Availableconcentration(units/mL)

= 14,000units/25,000units/mL

= 0.56mL.

Round the answer to the nearest tenth.

= 0.6mL.

A. Explain the purpose of a low bacteria diet. B. Use standard precautions and wear a mask. C. Monitor the client's white blood cell count (WBC). D. Institute contact precautions for staff and visitors. E. Send wound drainage for culture and sensitivity.

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

Explanation

A. Explain the purpose of a low bacteria diet: A low bacteria (neutropenic) diet is indicated for immunocompromised clients, not for MRSA wound infections. It does not reduce transmission or address wound healing.

B. Use standard precautions and wear a mask: Standard precautions are necessary, but a mask is not required for MRSA unless there is risk of aerosolization (e.g., respiratory infection). The key precaution is contact isolation, not routine mask use.

C. Monitor the client’s white blood cell count (WBC): Tracking WBC trends helps identify worsening infection or systemic involvement such as sepsis. This is an important part of managing MRSA.

D. Institute contact precautions for staff and visitors: MRSA is transmitted by direct contact with infected drainage or contaminated surfaces, so gown and glove use with contact precautions are essential.

E. Send wound drainage for culture and sensitivity: Culturing identifies the causative organism and determines antibiotic sensitivity, which guides effective treatment planning.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once day for a client who weighs 154 pounds. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.6"]

Explanation

A client with foul smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care (POC)? Select all that apply.

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

Explanation

The nurse plans to collect a 24 hour urine specimen for a creatinine clearance test. Which instruction should the nurse provide to the adult male client?

A client who is receiving zidovudine reports the appearance of pinpoint, red, round spots on the skin. Which result should the nurse report to the healthcare provider (HCР)?

Patient Data Exhibits Which laboratory test(s) would be helpful in determining the plan of care (POC) for this client? Select all that apply.

The nurse completes percussion of the abdomen on an older adult client. Which finding is considered normal for this client?

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?