A nurse is monitoring a client who is admitted with severe hemorrhage from traumatic injury who is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

Weight

Heart rate

Urine output

Answer and Explanation

The Correct Answer is B

A. Weight may fluctuate but is not a direct indication of immediate fluid resuscitation adequacy.
B. A decrease in heart rate is a sign of improved perfusion and stabilization, suggesting that fluid replacement is effective in compensating for blood loss.
C. Adequate fluid replacement is indicated by an increase, not a decrease, in urine output.
D. Blood pressure should stabilize or increase with fluid replacement, rather than decrease.

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

Explanation

A. Monitoring blood glucose levels is not directly related to managing fluid volume excess.
B. Weighing the client daily is essential for monitoring fluid retention and the effectiveness of interventions.
C. Preparing for hemodialysis is only necessary for severe fluid overload unresponsive to other treatments.
D. Restricting sodium in the diet helps prevent further fluid retention and supports management of FVE.
E. Changing IV fluids to D5W is not appropriate, as it could exacerbate fluid volume excess by increasing fluid load.

A. "I will check my urine once a day for ketones." B. "I will check my blood glucose every 4 hours when I am sick." C. "I will notify my provider if pre-meal glucose is 120 mg/dL." D. "I will check blood glucose every 5 minutes when lightheaded."

Correct Answer is B

Explanation

A. Checking urine for ketones is generally recommended when blood glucose is consistently high, but once daily may not be sufficient during illness or hyperglycemic episodes.
B. Monitoring blood glucose every 4 hours during illness helps manage potential fluctuations and prevent diabetic ketoacidosis, making this statement correct.
C. A pre-meal blood glucose of 120 mg/dL is within the acceptable range, so notifying the provider is unnecessary.
D. Checking blood glucose every 5 minutes is excessive and not standard practice, even if feeling lightheaded.

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A nurse is monitoring a client who is admitted with severe hemorrhage from traumatic injury who is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse documents that the client has a problem of fluid volume excess (FVE). Which intervention should the nurse include in the plan of care? Select all that apply.

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

Explanation

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Correct Answer is B

Explanation

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