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 D
Explanation
A. A filter needle is used when withdrawing medication from an ampule, but it is not used to administer the injection. After withdrawal, the filter needle should be replaced with a regular IM needle for administration.
B. The ampule should be broken by snapping the neck away from the body, not by bending it to the side, to prevent injury.
C. The nurse should gently tap the top of the ampule, not the bottom, to move the solution downward before opening.
D. The correct technique is to insert the needle into the center of the ampule to withdraw medication, ensuring that the bevel remains below the fluid line to avoid drawing up air.
Correct Answer is A
Explanation
A. Cleansing the injection site is important to reduce the risk of infection.
B. Sterile gloves are not typically required for administering subcutaneous injections unless there is a specific indication, such as when dealing with a client who has a compromised immune system or if there is potential for exposure to bodily fluids.
C. Pinching the skin can help in creating a fold where the needle can be inserted. However, there is no standard recommendation on which hand should be used.
D. Subcutaneous injections are typically administered at a 45-degree or 90-degree angle to the client's skin, depending on the amount of subcutaneous tissue present.
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