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 C
Explanation
A. Leaving small air bubbles in the new infusion tubing is incorrect. Air bubbles should be primed out of the tubing before use to prevent air embolism.
B. Inserting the new device distal to the old IV site is incorrect. The new IV site should be placed proximal to the old site to avoid complications from previous catheter use and ensure proper circulation.
C. Wearing clean gloves during the new IV insertion is correct. Clean gloves are appropriate when inserting a new short peripheral IV device. Sterile gloves are generally required for more invasive procedures, but when changing the device itself, clean gloves are sufficient.
D. Shaving the hair on the client's skin before inserting the new IV is incorrect. Shaving the skin is not recommended because it can cause small nicks that increase the risk of infection. Clipping the hair, if necessary, is the preferred method.
Correct Answer is D
Explanation
D. Numbness and tingling of the hands and feet can indicate peripheral neuropathy, a known adverse effect of nitrofurantoin. It's essential for the nurse to recognize and communicate the potential seriousness of these symptoms to the client.
A. Numbness and tingling are not typically related to hydration status. While adequate hydration is important for overall health, it does not directly prevent numbness and tingling caused by medication side effects.
B. Symptoms like urinary frequency, burning, and dysuria are common symptoms of a urinary tract infection, not indicators of the medication working.
C Numbness and tingling of the hands and feet can be indicative of peripheral neuropathy, which is a potential adverse reaction to nitrofurantoin. While not all cases are severe, it's crucial to assess the severity and duration of these symptoms and notify the healthcare provider.
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