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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D Excessive use of bisacodyl or other laxatives can indeed cause these adverse effects. Rectal burning can occur due to irritation from frequent bowel movements, while dehydration and electrolyte imbalance can result from fluid loss caused by frequent laxative use.
A. While regular bowel movements are important for many individuals, daily bowel movements are not necessary for everyone and can vary depending on diet, hydration, and individual health conditions.
B. Bisacodyl is a stimulant laxative used for short-term relief of constipation. It does not interact with dietary fiber intake, nor should the client necessarily decrease high-fiber foods unless specifically advised by their healthcare provider for other reasons.
C. Chronic use of bisacodyl, a stimulant laxative, can indeed lead to dependence and potentially harmful effects on the body's water and salt balance
Correct Answer is A
Explanation
A. IV solutions and administration sets should typically be changed every 48 to 72 hours to reduce the risk of contamination and infection. This interval helps prevent the buildup of bacteria in the solution and tubing, which could lead to bloodstream infections (BSIs).
B. Checking the client's IV site every is also important for monitoring for signs of infection, infiltration, or phlebitis. However, every 8 hours is too frequent and unnecessary
C. IV tubing should be changed every 72 hours not every 96 hours. Prolonging the use of IV tubing beyond this timeframe increases the risk of bacterial contamination and infection.
D. Transparent dressings are usually changed every 5 to 7 days, or sooner if they become soiled or compromised.
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