A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

Turgor.

Blood pressure.

Weight.

Lung sounds.

Answer and Explanation

The Correct Answer is C

A. Turgor is not a reliable indicator of fluid balance in clients with fluid volume overload, as it is more commonly used to assess dehydration.

B. Blood pressure is affected by fluid volume but is not a direct or specific measure of fluid balance. Other factors, such as medication or underlying conditions, can influence blood pressure.

C. Weight is the most accurate and sensitive indicator of fluid balance. A change in weight directly correlates with fluid retention or loss, making it the preferred method for evaluating fluid balance.

D. Lung sounds can indicate fluid overload if crackles are present, but they are not a quantitative measure of fluid balance and do not provide ongoing assessment of fluid changes.

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Correct Answer is A

Explanation

A. A private room with both contact and airborne precautions is appropriate for a client with varicella zoster virus (chickenpox or shingles in an immunocompromised state). This virus can spread through direct contact with lesions and airborne transmission of respiratory droplets.

B. A semiprivate room with a roommate who has the same diagnosis and airborne precautions could be considered if the roommate also has the same strain of the virus, but a private room is generally preferred to minimize cross-contamination risks.

C. A private room with both standard and droplet precautions is insufficient. Airborne precautions are necessary because varicella zoster virus can spread via airborne routes.

D. A semiprivate room with a roommate who has the same diagnosis and contact precautions does not account for the airborne transmission risk, making this option inappropriate.

A. Identify effective pain relief measures. B. Provide a numeric pain scale. C. Observe body language and movement. D. Ask the client to describe the pain.

Correct Answer is D

Explanation

A. Identify effective pain relief measures is important but not the first step in assessing pain quality. The nurse must first assess the pain itself before determining what interventions are effective.

B. Provide a numeric pain scale is commonly used to assess the intensity of pain, but it does not address the quality of pain. The numeric scale helps measure the severity, but it does not capture how the pain feels.

C. Observe body language and movement can provide clues about pain but does not give a comprehensive understanding of the pain's quality. While useful for assessing nonverbal clients, this approach alone does not provide detailed information about the pain experience.
D. Ask the client to describe the pain is the best approach for assessing the quality of pain. By asking the client to describe the pain, the nurse can gather information about its characteristics, such as sharp, dull, burning, or aching, which provides insight into the nature of the pain and helps guide appropriate interventions.

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A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being admitted to the unit with a varicella zoster virus infection. Which room should the charge nurse assign to the client?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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