A nurse is assessing a client with congestive heart failure (CHF). Which assessment tool will provide a reliable measure of fluid retention for this client?
Cardiac monitoring
Daily weight measurement
Blood pressure monitoring
Urine output measurement
The Correct Answer is B
Choice A Reason:
Cardiac monitoring involves the continuous observation of the heart’s electrical activity, typically using an electrocardiogram (ECG). While cardiac monitoring is essential for detecting arrhythmias and other cardiac events, it does not directly measure fluid retention. Fluid retention in CHF patients can lead to symptoms such as edema and weight gain, which are not directly assessed through cardiac monitoring.
Choice B Reason:
Daily weight measurement is a reliable and practical method for assessing fluid retention in clients with congestive heart failure. Fluid retention leads to an increase in body weight, and monitoring daily weight changes can help detect fluid accumulation early. A sudden weight gain of more than 2-3 pounds in a day or 5 pounds in a week is a significant indicator of fluid retention and worsening heart failure. This method is non-invasive, easy to perform, and provides valuable information for managing CHF.
Choice C Reason:
Blood pressure monitoring is crucial for managing clients with CHF, as hypertension can exacerbate heart failure. However, blood pressure readings alone do not provide a direct measure of fluid retention. While fluid overload can affect blood pressure, it is not a specific or sensitive indicator of fluid status. Blood pressure monitoring should be used in conjunction with other assessment tools to manage CHF effectively.
Choice D Reason:
Urine output measurement is an important parameter for assessing kidney function and fluid balance. In clients with CHF, reduced urine output can indicate worsening heart failure and fluid retention. However, urine output alone may not provide a complete picture of fluid status, especially if the client is on diuretic therapy. Daily weight measurement remains a more direct and reliable method for assessing fluid retention in CHF patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
Hyperkalosis is incorrect. Hyperkalosis refers to an elevated level of potassium in the blood, which is not directly related to the pH level. While hyperkalemia can occur in acidosis, it is not the primary condition indicated by a low pH
Choice B Reason:
Hyponatremia is incorrect. Hyponatremia refers to low sodium levels in the blood. It does not directly affect the pH level and is not indicated by the pH value provided.
Choice C Reason:
Acidosis is correct. The normal pH range for arterial blood is 7.35 to 7.45. A pH of 7.10 is below this range, indicating that the blood is too acidic. This condition is known as acidosis.
Choice D Reason:
Alkalosis is incorrect. Alkalosis refers to a condition where the blood pH is higher than the normal range, indicating that the blood is too basic. A pH of 7.10 is too low, not too high, and therefore indicates acidosis.
Correct Answer is A
Explanation
Choice A Reason:
A 24-hour urinary output of 380 mL indicates oliguria. Oliguria is defined as a urine output of less than 400-500 mL per day in adults. This condition can be caused by various factors, including dehydration, kidney dysfunction, or postoperative complications. Monitoring urine output is crucial for assessing kidney function and overall fluid balance, especially after major surgeries like a colon resection.
Choice B Reason:
A 24-hour urinary output of 550 mL is slightly above the threshold for oliguria. While it is still relatively low, it does not meet the strict criteria for oliguria, which is typically defined as less than 400-500 mL per day. This output suggests that the client is producing an adequate amount of urine, though it may still warrant close monitoring to ensure it does not decrease further.
Choice C Reason:
A 24-hour urinary output of 600 mL is within the normal range and does not indicate oliguria. Normal urine output for adults is generally considered to be around 800-2000 mL per day, depending on fluid intake and other factors. This output suggests that the client’s kidneys are functioning properly and that there is no immediate concern for oliguria.
Choice D Reason:
A 24-hour urinary output of 720 mL is also within the normal range and does not indicate oliguria. This output is closer to the lower end of the normal range but still suggests adequate kidney function. It is important to continue monitoring the client’s urine output to ensure it remains within a healthy range, especially after surgery.
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