What is the best indication if the client with congestive heart failure is holding excess fluid?
Intake and output
Pitting pedal edema
Crackles in the bases of the lungs
Daily weights
The Correct Answer is D
A. Intake and output:
Intake and output refer to monitoring the amount of fluids a person consumes (intake) and eliminates (output) through urine, feces, and other means. While tracking fluid intake and output is important, it may not provide a direct indication of excess fluid retention.
B. Pitting pedal edema:
Pitting pedal edema is swelling in the lower extremities, particularly the ankles and feet, that leaves an indentation (pit) when pressure is applied. This can be a sign of fluid retention but may not always be the earliest or most reliable indicator.
C. Crackles in the bases of the lungs:
Crackles or rales in the bases of the lungs can be indicative of pulmonary congestion, which may occur due to fluid accumulation. However, crackles alone may not always be specific to fluid overload and can be present in other respiratory conditions.
D. Daily weights:
Daily weights are a critical and sensitive measure for assessing fluid balance. Sudden weight gain, especially over a short period, can be a strong indicator of fluid retention. Monitoring weight on a daily basis helps to detect changes early, allowing for prompt intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50"]
Explanation
To calculate the drops per minute for the ondansetron infusion, we need to use the formula:
drops per minute = (volume in mL x drop factor) / time in minutes
In this case, the volume is 50 mL, the drop factor is 15 gtt/mL, and the time is 15 minutes. Plugging these values into the formula, we get:
drops per minute = (50 x 15) / 15
drops per minute = 750 / 15
drops per minute = 50
Therefore, the nurse should set the infusion pump to deliver 50 drops per minute of ondansetron to the client with severe nausea.
Correct Answer is D
Explanation
A. Diaphragmatic breathing:
Diaphragmatic breathing, also known as abdominal or deep breathing, is a normal and effective way of breathing. It involves the contraction and relaxation of the diaphragm, allowing for efficient lung expansion. This is a healthy and efficient breathing technique.
B. Controlled breathing:
Controlled breathing refers to a deliberate and regulated breathing pattern. It can include techniques such as paced breathing, where the individual consciously controls the rate and depth of their breaths. Controlled breathing is generally considered a positive and intentional approach to managing respiratory function.
C. Pursed-lip breathing:
Pursed-lip breathing is a breathing technique where the individual breathes in through the nose and exhales through pursed lips. This method is often taught to individuals with certain respiratory conditions, such as chronic obstructive pulmonary disease (COPD), to help improve lung function and alleviate shortness of breath. Pursed-lip breathing can be a helpful strategy in specific situations.
D. Use of accessory muscles:
The use of accessory muscles indicates that the person is experiencing increased difficulty in breathing. Accessory muscles, such as the neck and shoulder muscles, are not typically heavily involved in breathing under normal circumstances. When these muscles are visibly working during breathing, it suggests increased respiratory effort and can be a sign of respiratory distress or difficulty.
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