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 D
Explanation
Explanation: In clients with COPD, the secretions tend to be thick and sticky, which makes it difficult to cough up and clear the airway. To promote respiratory hygiene in this situation, the nurse should recommend increasing fluid intake. Adequate hydration helps to thin the secretions, making them easier to expectorate. The client should aim to drink at least 8-10 glasses of water or other fluids per day unless there is a medical reason not to do so.
Decreasing fluid intake (option a) would make the secretions even thicker and more difficult to clear. Taking Tylenol for secretions (option b) is not a recommended intervention as Tylenol is not indicated for thinning of secretions. Range-of-motion exercises (option c) are important to prevent complications such as pneumonia, but they are not directly related to promoting respiratory hygiene in this situation.
Correct Answer is A
Explanation
Difficulty breathing is a sign of a potential transfusion reaction. When a client reports difficulty breathing during a blood transfusion, the nurse should stop the transfusion immediately to prevent the reaction from worsening. Once the transfusion is stopped, the nurse can then assess the client's vital signs and notify the healthcare provider of the client's response. Documentation of the findings should also be completed after the client's condition has stabilized. However, stopping the transfusion takes priority over documenting the findings.
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