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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Place the wheelchair on the client's left side is the most appropriate action. Since the client has right-sided hemiplegia, the nurse should place the wheelchair on the client's left side to allow for easier transfer. The left side is the stronger side, and the client will be able to use this side to assist with the transfer.

B. Instruct the client to take slow, deep breaths while transferring may help with relaxation, but it is not the priority in this scenario. The focus should be on positioning and safety during the transfer.

C. Instruct the client to look at his feet is not advisable because it may disrupt the client's balance or lead to a fall. The client should focus on using the stronger side to assist with the transfer.

D. Have the client put both arms around the nurse's neck for support is not safe and could cause strain or injury to both the client and the nurse. The client should be instructed to use proper body mechanics and rely on the nurse for support during the transfer, but not in a way that could lead to injury.

A. Notify the client's next of kin prior to surgery. B. Encourage the client to execute a will that identifies a guardian for her children. C. Flag the client's record with "do not resuscitate." D. Document the client's statement on the admission form. E. Explain the benefit of executing an advanced directive.

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

Explanation

A. Notify the client's next of kin prior to surgery is not appropriate unless the client provides explicit consent. The nurse must respect the client's autonomy and confidentiality.

B. Encourage the client to execute a will that identifies a guardian for her children is outside the nurse's role. While the client’s family arrangements are important, this is not directly relevant to the surgical admission process.

C. Flag the client's record with "do not resuscitate" is not appropriate unless the client has completed the necessary documentation, such as an advance directive or physician orders for life-sustaining treatment (POLST).

D. Document the client's statement on the admission form is essential to ensure the healthcare team is aware of the client’s expressed wishes.

E. Explain the benefit of executing an advanced directive is appropriate because it informs the client about formalizing their wishes to avoid potential confusion during medical care.

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 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 male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, which action should the nurse take?

Correct Answer is A

Explanation

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

Explanation

A client is being discharged postsurgery. Which information provided by the client requires additional instruction by the nurse?

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?

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

A client's spouse has just learned of the client's terminal illness. The spouse is sitting in the corner of the client's room crying, and says to the nurse, "I feel as if I'm already so alone." Which action should the nurse take first?

While preparing to obtain a stool specimen for occult blood, the nurse observes that the client's feces is soft, solid, and light brown. Which action should the nurse implement?