A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
Edema presence
Skin turgor
Urine output
Daily weight
The Correct Answer is D
Choice A reason: This statement is false. Edema is a sign of fluid overload, not fluid deficit. Edema occurs when fluid accumulates in the interstitial space due to increased capillary hydrostatic pressure or decreased plasma oncotic pressure. Edema is more common in patients with heart failure, liver disease, or kidney disease¹.
Choice B reason: This statement is false. Skin turgor is a measure of skin elasticity and hydration. It can be affected by factors such as age, skin condition, and ambient temperature. Skin turgor is not a reliable indicator of fluid balance, as it can be normal in patients with mild to moderate hypovolemia².
Choice C reason: This statement is false. Urine output is a measure of kidney function and fluid excretion. It can be influenced by factors such as fluid intake, diuretics, hormones, and renal diseases. Urine output is not a sensitive indicator of fluid balance, as it can be normal or even increased in patients with hypovolemia due to compensatory mechanisms.
Choice D reason: This statement is true. Daily weight is a measure of body mass and fluid status. It can reflect changes in fluid balance more accurately than other methods, as long as the weight is measured at the same time, on the same scale, and with the same clothing each day. A decrease in weight can indicate fluid loss due to hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.4"]
Explanation
The nurse should administer 1.4 mL of Heparin to the patient.
To calculate the number of milliliters (mL) the nurse should administer, we can use the following steps:
Step 1: Calculate the total amount of Heparin available in mL
Heparin concentration: 5,000 units per mL
Ordered Heparin dose: 7,000 units
Total mL of Heparin needed = Ordered dose / Heparin concentration
Total mL = 7,000 units / 5,000 units per mL = 1.4 mL
Correct Answer is B
Explanation
Choice A reason: This statement is false. Asking the patient about home insulin doses is not the action that the nurse should take first. Insulin is a hormone that lowers the blood glucose level and can also lower the blood potassium level by driving potassium into the cells. However, this is not the primary cause of hypokalemia, or low blood potassium level, which can be due to other factors such as diuretics, vomiting, diarrhea, or alkalosis.
Choice B reason: This statement is true. Administering IV potassium supplements is the action that the nurse should take first. Potassium is an electrolyte that is essential for the normal function of the heart, muscles, and nerves. Hypokalemia can cause cardiac arrhythmias, muscle weakness, and paralysis. IV potassium supplements can restore the blood potassium level and prevent life-threatening complications.
Choice C reason: This statement is false. Placing the patient on a cardiac monitor is not the action that the nurse should take first. A cardiac monitor is a device that records the electrical activity of the heart and can detect any abnormal rhythms or conduction problems. It is a useful tool for monitoring the patient's cardiac status, but it does not treat the underlying cause of hypokalemia.
Choice D reason: This statement is false. Starting an insulin infusion at 0.1 units/kg/h is not the action that the nurse should take first. Insulin infusion is a method of delivering insulin continuously through a pump or a catheter. It is used for patients with diabetes who need tight glucose control. It can also lower the blood potassium level by driving potassium into the cells. However, this is not t
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.