Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

Palpate the rate and volume of the pulse.

Check fingernails for the presence of clubbing.

Measure body weight at the same time daily

Observe the color and amount of urine

Compare muscle strength of both arms.

Answer and Explanation

Correct Answer : A,C,D

The PN should palpate the rate and volume of the pulse, measure body weight at the same time daily, and observe the color and amount of urine when assessing a client for signs and symptoms of ﬂuid volume excess. These actions can help detect changes in the cardiovascular, renal, and ﬂuid balance systems that may indicate ﬂuid overload, such as tachycardia, bounding pulse, weight gain, edema, oliguria, or dark urine.

The other options are not correct because:

b. Checking fingernails for the presence of clubbing is not relevant for assessing ﬂuid volume excess, as clubbing is a sign of chronic hypoxia or lung disease that causes enlargement of the fingertips and nails.

e. Comparing muscle strength of both arms is not relevant for assessing ﬂuid volume excess, as muscle weakness is not a specific sign of ﬂuid overload, but may be caused by various factors such as electrolyte imbalance, nerve damage, or fatigue.

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Correct Answer is C

Explanation

A) Incorrect- While understanding the frequency that a problem occurs can provide context to its significance and potential impact, it is not the most important consideration when gathering evidence for evidence-based decision-making. The frequency alone does not ensure that the evidence collected will be directly applicable to the current situation.
B) Incorrect- Personal values are subjective and may influence an individual's perspective, but they are not the primary consideration when gathering evidence for evidence-based decision- making. Evidence-based practice aims to rely on objective and scientifically validated information rather than personal values, which can vary greatly among individuals.
C) Correct- The most important consideration when gathering evidence is its relevance to the specific situation at hand. Evidence must directly address the problem and clinical question, ensuring that the information collected is applicable, appropriate, and reliable for guiding decision-making in the current context.
D) Incorrect- While past experiences can offer insights, they are not the most important consideration for evidence-based decision-making. Relying solely on past experiences may not account for new developments, changing guidelines, or unique aspects of the current situation that were not present in previous encounters.

A. Pupillary response. B. Peripheral pulses. C. Bowel patterns. D. Oxygen saturation.

Correct Answer is C

Explanation

A) Incorrect- Pupillary response is not relevant to the assessment of mesalamine's effectiveness.

Pupillary response is often assessed in neurological or ophthalmic evaluations and is not a direct measure of gastrointestinal function or the response to mesalamine therapy.

B) Incorrect- Peripheral pulses are not directly affected by mesalamine therapy, and monitoring them would not provide insight into the medication's effectiveness. Peripheral pulses are
typically assessed to evaluate the circulatory status and are not specific to the evaluation of gastrointestinal conditions.
C) Correct- Mesalamine is a medication commonly used to treat inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis. It helps to reduce inflammation in the gastrointestinal tract. Monitoring bowel patterns is important to assess the effectiveness of mesalamine in managing the symptoms of these conditions.
D) Incorrect- Oxygen saturation is a measure of the amount of oxygen in the blood and is used to assess respiratory function. While oxygen saturation is important for overall patient assessment, it is not directly related to mesalamine's effectiveness in treating inflammatory bowel disease.

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Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A client is receiving mesalamine 800 mg by mouth three times a day. Which assessment should the nurse perform to assess the effectiveness of the medication?

Correct Answer is C

Explanation

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