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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: This statement is false. Drinking more fluids in the late evening can cause nocturia, which is the need to urinate frequently at night. This can disrupt the sleep cycle and increase the risk of falls.

Choice B reason: This statement is true. Dry mouth is a sign of dehydration and indicates the need for more fluid intake. Older adults may have reduced thirst sensation and may not drink enough fluids throughout the day.

Choice C reason: This statement is false. Caffeine is a diuretic, which means it increases urine output and can worsen dehydration. Confusion is a symptom of dehydration and requires immediate medical attention.

Choice D reason: This statement is false. Feeling full is not a reliable indicator of hydration status. Older adults may have decreased appetite and gastric motility, which can make them feel full even when they are dehydrated.

A. The patient’s radial pulse is 105 beats/min B. There is sediment and blood in the patient’s urine C. There are crackles throughout both lung fields D. The blood pressure increases from 120/80 to 142/94 mm Hg

Correct Answer is C

Explanation

Choice A reason: This statement is false. The patient’s radial pulse is 105 beats/min is not the assessment data that will require the most rapid response by the nurse. A high pulse rate can indicate dehydration, anxiety, or fever, but it is not a life-threatening condition.

Choice B reason: This statement is false. There is sediment and blood in the patient’s urine is not the assessment data that will require the most rapid response by the nurse. Sediment and blood in the urine can indicate kidney damage, infection, or trauma, but they are not an immediate complication of hyponatremia.

Choice C reason: This statement is true. There are crackles throughout both lung fields is the assessment data that will require the most rapid response by the nurse. Crackles are abnormal lung sounds that indicate fluid accumulation in the alveoli, which can impair gas exchange and cause respiratory distress. Crackles can be a sign of pulmonary edema, a serious complication of hyponatremia that requires prompt treatment.

Choice D reason: This statement is false. The blood pressure increases from 120/80 to 142/94 mm Hg is not the assessment data that will require the most rapid response by the nurse. A high blood pressure can indicate fluid overload, stress, or pain, but it is not a critical condition.

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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?

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Naxlex Comprehensive Predictor Exams

The home health nurse cares for an alert and oriented older adult patient with a history of dehydration. Which instructions should the nurse give this patient related to fluid intake?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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