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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Provide a box of tissues for the client to use when coughing is a helpful action for promoting hygiene and comfort. However, this does not address the potential risk of infection transmission to staff and others in the room.
B. Obtain face masks for staff to wear upon entering the room is the most appropriate action. The client is coughing, and non-productive coughing can still release droplets that may carry infectious agents. Wearing face masks helps protect staff and other individuals from potential exposure to airborne pathogens.
C. Assist the client in changing into a fresh hospital gown is a considerate action but does not directly address the immediate concern of infection control. The priority here is preventing the spread of potential infectious particles.
D. Teach the client to cover the mouth with hands when coughing is incorrect. The client should cover their cough with their elbow or a tissue, not with their hands, to prevent spreading germs. Teaching this technique is important but does not address the immediate need for protective measures for staff.
Correct Answer is ["C","D"]
Explanation
A. Use at least 2 client identifiers before administering a dose – This is a critical step in preventing medication errors, but it would not have prevented the error in this scenario. The issue was with the dosage of the medication, not the identification of the client.
B. Document all medication as soon as it is given – While documentation is important for patient safety, it does not directly address the error of giving the wrong dose. Proper calculation and verification of the dose before administration are more effective in preventing this type of error.
C. Question unusually large or small doses – This is a key technique for preventing medication errors. The nurse should have questioned the unusually large dose of potassium, which was not calculated based on the client's weight and the prescribed amount. This would have alerted the nurse to the error before administering the medication.
D. Double check the dosage of high-risk medications with another nurse – Potassium is considered a high-risk medication, and double-checking the dosage with another nurse would have been an effective safety measure. This technique helps to catch errors in dosage calculations, especially with medications that have narrow therapeutic windows like potassium.
E. Involve and educate clients in medication administration – While involving and educating clients is important for overall safety and understanding, it is not a technique that would have helped prevent this particular medication error. The error was related to the nurse’s calculation and administration of the dose, not the client's involvement.
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