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 D

Explanation

Atrial fibrillation is a common arrhythmia, and diuretics are often used in the management of patients with this condition to help control ﬂuid balance. However, diuretics can cause electrolyte imbalances, especially hypokalaemia (low potassium levels), which can lead to muscle cramps and other complications.

A Complete Metabolic Panel (CMP) is a blood test that measures various electrolytes, glucose, and other important components. Among the options given, the most likely lab value to be abnormal in Patient MK's case is a low level of potassium (K+), which is consistent with her symptoms and diuretic use. Option d, K+ -

1. mEq/L, is the correct option as it represents a low level of potassium, which is defined as a value less than 3.5 mEq/L.

Option a, Mg2 – 20 mEq/L, represents high magnesium levels, which are not typically associated with diuretic use or muscle cramps. Option b, Na+ - 123 mEq/L, represents low sodium levels, which are less likely to occur with diuretic use, and are typically associated with other conditions. Option c, Ca2 – 10.0 mg/dl, represents normal calcium levels and is not typically aﬀected by diuretic use.

A. Stop the transfusion. B. Notify the health care provider of the client s response. C. Check the client s vital signs. D. Document the findings.

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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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

Patient MK is admited with Atrial Fibrillation an irregular heart rhythm. She is also complaining of muscle cramps to her legs and that she started a new diuretic last week. What lab value are you most likely to find on her Complete Metabolic Panel?

Correct Answer is D

Explanation

A nurse is administering a blood transfusion to a client. After 15 minutes, the client reports difficulty breathing. What is the first action by the nurse?

Correct Answer is A

Explanation

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