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. Remove client identifying information of those who participate is correct because protecting client confidentiality is a fundamental principle of ethical nursing practice. De-identifying data ensures compliance with privacy regulations like HIPAA.

B. Implement full disclosure policy especially when giving examples is not appropriate as sharing identifiable client information, even with disclosure, violates privacy laws.

C. Respect all copyright laws when adding website content is important but does not directly address client privacy, which is the primary concern in this scenario.

D. May use information from the client's relatives instead still violates privacy laws if the information is related to the client’s care, even if shared by relatives.

A. Warm, dry skin with a fever of 100.0° F (37.8° C). B. 4+ pitting edema of both lower extremities. C. A Braden risk assessment scale rating score of ten. D. Hypoactive bowel sounds with infrequent bowel movements.

Correct Answer is C

Explanation

A. Warm, dry skin with a fever of 100.0° F (37.8° C) is not directly related to the need for frequent turning. A fever and warm, dry skin may indicate an infection or another underlying condition, but it does not prioritize the need for turning in the context of pressure injury prevention.

B. 4+ pitting edema of both lower extremities may indicate fluid retention, but it is not as directly related to the risk of developing pressure injuries. Although edema can impact skin integrity, the Braden scale score is a more reliable indicator for turning schedules to prevent pressure ulcers.

C. A Braden risk assessment scale rating score of ten is the most important factor in determining the turning schedule. A score of ten indicates a high risk for developing pressure ulcers, which is directly related to the need for frequent repositioning to relieve pressure and prevent skin breakdown.

D. Hypoactive bowel sounds with infrequent bowel movements may be a concern for gastrointestinal function, but it does not directly affect the turning schedule. The Braden scale score is a better indicator for deciding how often the client needs to be turned to prevent pressure injuries.

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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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