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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
In case of suspected ingestion of a poisonous substance, the priority response of the poison control nurse should be to assess the child's vital signs, especially breathing and heart rate, to determine if the child is experiencing any immediate life-threatening symptoms. This information will help the nurse determine the appropriate course of action, such as whether to instruct the caregiver to perform CPR or to immediately call for emergency medical assistance.
Asking about the substance ingested and the time of ingestion are also important pieces of information to gather, but they should not take priority over assessing the child's vital signs. Inducing vomiting is generally not recommended unless instructed to do so by a medical professional, as it can cause further harm if the substance ingested is corrosive or caustic.
Correct Answer is B
Explanation
Hypertonic solutions have a higher concentration of solutes (such as sodium, glucose, or mannitol) than the fluid in the body's cells, causing water to move out of the cells and into the bloodstream. This results in the shrinking of the cells and an increase in extracellular fluid volume.
Examples of hypertonic solutions include 10% dextrose in water (D10W), 3% saline, and 5% dextrose in 0.9% saline.
In contrast, isotonic solutions have the same concentration of solutes as the fluid in the body's cells, and hypotonic solutions have a lower concentration of solutes than the fluid in the body's cells.
Therefore, in this scenario, the nurse should administer a hypertonic solution to the client who requires IV fluids.
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