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.
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Related Questions
Correct Answer is D
Explanation
D. Tachycardia refers to an elevated heart rate. In circulatory overload, the heart may attempt to compensate for the increased fluid volume by pumping faster. This compensatory mechanism aims to maintain adequate tissue perfusion despite the excessive fluid burden.
A. Diaphoresis refers to excessive sweating. It is not typically associated with circulatory overload. Instead, diaphoresis can occur in conditions such as fever, anxiety, or during physical exertion.
B Hypotension refers to low blood pressure. In circulatory overload, the excess fluid in the circulatory system can lead to increased blood pressure rather than hypotension. Hypotension is more commonly associated with hypovolemia (low blood volume) rather than hypervolemia.
C. Weight loss is not a characteristic finding in circulatory overload. On the contrary, patients with fluid overload often experience weight gain due to retained fluid in the body tissues and bloodstream.
Correct Answer is B
Explanation
B. This range represents the normal serum magnesium level. It is important for maintaining neuromuscular function and other vital processes in the body.
A. This range is too low for normal serum magnesium levels. Magnesium levels below this range can indicate hypomagnesemia, which can lead to symptoms such as muscle cramps, tremors, and cardiac arrhythmias.
C. This range is too high for normal serum magnesium levels. Elevated magnesium levels (hypermagnesemia) can occur in conditions such as renal failure or excessive magnesium intake, leading to symptoms like weakness, decreased reflexes, and in severe cases, cardiac arrest.
D. While this range is broader and includes the correct normal range (1.3-2.1 mEq/L), it also includes values that are below and above normal. Values below 1.3 mEq/L can indicate hypomagnesemia, while values above 2.1 mEq/L can indicate hypermagnesemia.
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