A patient with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the patient's fluid balance?
Skin turgor.
Weight.
Blood pressure.
Lung sounds.
The Correct Answer is B
Choice A reason: Skin turgor is a method to assess hydration status, but it is not the most accurate indicator of fluid balance in a patient with fluid volume overload.
Choice B reason: Monitoring weight is the most accurate method to assess fluid balance. A sudden increase or decrease in weight is indicative of fluid changes.
Choice C reason: Blood pressure can be affected by fluid volume changes, but it does not provide a direct measure of fluid balance.
Choice D reason: Lung sounds can indicate fluid overload in the lungs but do not give a complete picture of overall fluid balance.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Slip-on rubber shower shoes are not recommended as they do not provide the necessary support or stability for a client with weakness on one side.
Choice B reason: Tennis shoes with Velcro are ideal as they offer good support and are easy to fasten, which is beneficial for a client with one-sided weakness and potentially limited dexterity.
Choice C reason: Leather-soled loafers can be slippery and do not offer the snug fit and support needed for safe ambulation post-stroke.
Choice D reason: Rubber-soled slippers may provide some grip but typically do not offer the structured support that is necessary for a client with post-stroke weakness.
Correct Answer is C
Explanation
Choice A reason: Using normal saline to irrigate the wound is a correct practice and does not indicate a need for additional teaching. Normal saline is isotonic and is commonly used for wound irrigation because it does not interfere with the natural healing process.
Choice B reason: Cleaning from less soiled to more soiled areas is also a correct technique to prevent contamination of cleaner areas. This method helps to reduce the risk of infection and is a standard practice in wound care.
Choice C reason: Opening a sterile package towards the body is incorrect and indicates that additional teaching is needed. When opening a sterile package, it should be opened away from the body to maintain the sterility of the contents and prevent contamination.
Choice D reason: Placing soiled dressing in a plastic bag is a proper disposal method and does not indicate a need for additional teaching. It is important to properly dispose of soiled dressings to prevent the spread of infection.
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