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

This response provides the patient with accurate and reassuring information about the EKG procedure. It explains that the test is painless and describes what will happen during the test. The other responses do not provide as much information or reassurance to the patient.

A. Perform respiratory assessment. B. Document hypoxemia. C. Check the placement of the pulse oximeter. D. Report pulse oximetry to the health care provider.

Correct Answer is A

Explanation

Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.

Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.

While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.

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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

Your patient is ordered an EKG upon admission to the hospital. She is very scared and states she has never had one of these diagnostic tests before. Which answer is most appropriate by the nurse regarding EKG.

Correct Answer is A

Explanation

The nurse observes that the client’s pulse oximetry is 89%. What is the priority nursing action?

Correct Answer is A

Explanation

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