For a patient who is experiencing an ECV excess, the nurse plans to determine the fluid status. The best way for the nurse to determine the fluid balance for the patient is to:
obtain diagnostic test results
weigh the patient daily
monitor IV fluid intake
assess vital signs
The Correct Answer is B
B. Daily weight measurements are a practical and effective method to assess fluid balance. Changes in weight can reflect fluid retention or loss. Daily weighing is particularly useful for monitoring fluid status in patients with known or suspected fluid excess. It helps detect trends over time and guides adjustments in fluid management.
A. While diagnostic tests are crucial for assessing underlying causes and complications of fluid imbalance, they do not directly provide a real-time assessment of fluid balance or volume overload.
C. Monitoring IV fluid intake provides information on the amount of fluid input but does not directly indicate how the patient's body is handling or retaining that fluid. It complements other methods like daily weight measurements.
D. Vital signs are essential for assessing the hemodynamic status and response to fluid therapy but are not specific enough to quantify fluid balance or detect mild fluid excess without other signs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2"]
Explanation
To administer a dose of 250 mg of amoxicillin when only 125 mg tablets are available, the nurse would need to give two tablets. This is because each tablet contains 125 mg, and two tablets would equal the required dose of 250 mg
Correct Answer is D
Explanation
D. Muscle weakness is a hallmark sign of hypokalemia. Potassium is crucial for proper muscle contraction, and low levels can impair muscle function. This weakness can affect skeletal muscles (resulting in fatigue, cramps, or generalized weakness) as well as smooth muscles (contributing to constipation or other gastrointestinal symptoms).
A. Hypokalemia is not typically associated with hyperactive bowel sounds.
B. Cerebral edema is not typically associated with hypokalemia. Instead, cerebral edema can occur with conditions such as hyponatremia (low sodium levels) or other metabolic disturbances.
C. Hypokalemia is more commonly associated with hypotension (low blood pressure) rather than hypertension. Low potassium levels can affect vascular smooth muscle tone, potentially leading to vasodilation and hypotension.
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