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

Answer and Explanation

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.

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Correct Answer is A

Explanation

The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can aﬀect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.

While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.

Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.

Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.

A. give the ﬂuids quickly. B. monitor the amount of ﬂuid the client is receiving. C. if the ﬂuids are too low. increase them to infuse quicker. D. check the intravenous rate every two days.

Correct Answer is B

Explanation

: A client with renal disease may have impaired kidney function, which can aﬀect ﬂuid balance in the body. Giving ﬂuids too quickly or increasing the infusion rate too quickly can lead to ﬂuid overload,

which can exacerbate the client's condition. It is important for the nurse to monitor the amount of ﬂuid the client is receiving to ensure that the infusion rate is appropriate for the client's condition and to prevent ﬂuid overload. Checking the intravenous rate every two days is not sufficient; the nurse should monitor the rate regularly and adjust it as necessary based on the client's response.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The home care nurse visits a client with compromised lung function. The client has greenish yellow sputum with a musty odor. Which assessment is the priority for the

Correct Answer is A

Explanation

A client with renal disease requires IV ﬂuids. It is important for the nurse to:

Correct Answer is B

Explanation

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