A patient with congestive heart failure is at risk of excess fluid volume. Which intervention will best determine if the patient is beginning to have excess fluid volume?
Daily intake and output recordings
Daily weights
Daily blood pressure and heart rate checks
Daily CMP lab draw
The Correct Answer is B
Daily weights provide a reliable and accurate measure of fluid balance in the body. An increase in weight can indicate fluid retention and the need for further intervention. While daily intake and output recordings, blood pressure and heart rate checks, and CMP lab draws can also provide useful information, daily weights are the most effective way to monitor for excess fluid volume in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Daily weights provide a reliable and accurate measure of fluid balance in the body. An increase in weight can indicate fluid retention and the need for further intervention. While daily intake and output recordings, blood pressure and heart rate checks, and CMP lab draws can also provide useful information, daily weights are the most effective way to monitor for excess fluid volume in this situation.
Correct Answer is B
Explanation
Hyponatremia is a condition where the sodium levels in the blood are abnormally low. It can cause confusion, seizures, and even coma in severe cases. The IV fluids hanging are 0.33% NaCI, which means they have a low sodium concentration, and may be contributing to the patient's hyponatremia.
Given that the patient is becoming increasingly confused, it is important to assess his mental status and monitor him closely to prevent harm. However, restraining the patient should not be the first course of action. Instead, the nurse should focus on identifying the underlying cause of the hyponatremia and taking appropriate steps to address it.
Therefore, the next step would be to get an order for additional lab work to assess the patient's electrolyte levels and identify the cause of the hyponatremia. This will help to guide further treatment and management decisions for the patient.
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