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 D

Explanation

A. "The healthcare provider will share this information with you" implies that the father has the right to access the client’s information, which is incorrect unless the client has provided explicit consent.

B. "I'm sorry, but your son's medical information is none of your business" is inappropriate and dismissive. While the father does not have automatic rights to the information, the response should be respectful and professional.

C. "I can give you those results as soon as I get them back from the lab" violates the client’s privacy, as the father is not automatically entitled to this information without the client’s consent.

D. "I can only give medical information to your son because he is an adult" is correct because the client is 19 years old and legally an adult. Under privacy laws such as HIPAA, the nurse cannot share medical information with anyone, including parents, unless the client has given permission.

A. Complete an adverse occurrence/incident report. B. Ensure that the restraints are not too tight. C. Initiate the facility's restraint flow sheet. D. Demonstrate proper securing of the restraints.

Correct Answer is D

Explanation

A. Complete an adverse occurrence/incident report may be necessary if harm occurs, but the priority is to immediately correct the unsafe practice to prevent injury.

B. Ensure that the restraints are not too tight is important, but addressing the incorrect technique of securing restraints to the bedside rails takes precedence as it poses a greater risk to the client’s safety.

C. Initiate the facility's restraint flow sheet is part of documentation but does not address the immediate safety concern.

D. Demonstrate proper securing of the restraints is correct because restraints should never be secured to movable parts of the bed, such as the rails, as this can cause injury. The nurse must provide immediate education to the UAP to prevent harm and ensure the restraints are applied correctly.

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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?

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Naxlex Comprehensive Predictor Exams

A 19-year-old client is admitted to the hospital with severe right lower quadrant abdominal pain. The father is requesting to know his son's laboratory test results. Which is the best response for the nurse to provide?

Correct Answer is D

Explanation

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

Correct Answer is D

Explanation

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