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 C
Explanation
: Chest tube placement is done to remove air or fluid from the pleural space, which is the area between the lungs and the chest wall. The chest tube drainage system is an important tool to monitor and manage the drainage from the chest tube.
It is essential that the chest tube drainage system is placed below the level of the patient's chest and the site of insertion. This is necessary to create a continuous drainage system by allowing gravity to assist in the flow of air or fluid out of the pleural space. If the chest tube drainage system is placed above the insertion site, the fluid will not drain properly, which can cause the fluid to back up into the patient's chest cavity, leading to complications such as pneumothorax or hemothorax.
Therefore, the appropriate statement regarding a chest tube is that the chest tube drainage system must be placed below the site of insertion.
Correct Answer is A
Explanation
The use of an incentive spirometer is essential after surgery to prevent complications such as pneumonia and atelectasis. Atelectasis is the collapse of air sacs in the lungs, which can occur after surgery due to decreased respiratory effort and shallow breathing. An incentive spirometer helps the patient take deep breaths and increase their lung volume, preventing these complications.
Breathing rapidly to prevent pneumonia (option b) is not recommended as it can lead to hyperventilation and other respiratory complications.
Option c is incorrect because patient education is a crucial aspect of post-operative care, and the patient needs to be aware of the potential complications and how to prevent them.
The use of a chest tube (option d) is not usually required after hip surgery, and it is not a priority teaching for the patient.
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