Which intervention should the nurse implement to manage a client’s fluid and electrolyte balance?

Monitor daily urine output volume

Use salt tablets after strenuous exercise

Review food labels for sodium content

Drink plenty of water whenever thirsty

Answer and Explanation

The Correct Answer is A

Choice A reason: Monitoring daily urine output assesses kidney function and fluid balance, as urine volume reflects hydration and electrolyte homeostasis. Inadequate output signals dehydration or renal issues, allowing timely intervention to maintain fluid and electrolyte balance, making it the most effective nursing action.

Choice B reason: Salt tablets after exercise replace sodium lost in sweat but are not a universal intervention for fluid and electrolyte balance. They risk hypernatremia if overused. Monitoring urine output is more comprehensive, as it directly evaluates fluid status across various clinical scenarios.

Choice C reason: Reviewing food labels for sodium content helps manage dietary intake but is indirect and patient-dependent. Urine output monitoring provides objective data on fluid and electrolyte status, enabling timely adjustments in therapy, making it a more immediate and reliable intervention.

Choice D reason: Drinking water when thirsty supports hydration but relies on subjective thirst, which may be impaired in certain conditions. Monitoring urine output objectively assesses fluid balance, detecting imbalances early, making it a more proactive and precise intervention than thirst-driven hydration.

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Correct Answer is C

Explanation

Choice A reason: Throat irritation is a common albuterol side effect due to its deposition in the oropharynx during inhalation. It is not life-threatening and can be managed with rinsing or spacer use. This does not require immediate intervention compared to cardiovascular effects, as it does not compromise vital organ function.

Choice B reason: Uncontrollable shaking (tremors) is a frequent albuterol side effect, resulting from beta-2 receptor stimulation in skeletal muscles. It is usually transient and benign, not requiring immediate intervention. Monitoring is sufficient unless severe, as it does not pose an acute threat compared to cardiac irregularities.

Choice C reason: An irregular rapid heart rate (tachycardia or arrhythmia) is a serious albuterol side effect, as beta-2 agonists can stimulate beta-1 receptors in the heart, causing cardiovascular instability. This warrants immediate intervention, as it risks cardiac compromise, especially in emphysema patients with compromised respiratory and cardiac reserves.

Choice D reason: Increased anxiety is a possible albuterol side effect due to its stimulatory effects on the central nervous system. While distressing, it is not immediately life-threatening. It requires monitoring but is secondary to cardiovascular complications, which pose a greater acute risk in emphysema patients with wheezing.

A. Increased urine output B. Elevated blood pressure C. Increased heart rate D. Weight gain

Correct Answer is A

Explanation

Choice A reason: Furosemide, a loop diuretic, promotes urine output by inhibiting sodium reabsorption in the kidneys, reducing fluid overload in heart failure. Increased urine output indicates effective diuresis, alleviating pulmonary and peripheral edema, making it the primary sign of therapeutic efficacy.

Choice B reason: Elevated blood pressure is not an expected effect of furosemide, which reduces preload and blood volume, often lowering pressure. Effective diuresis is shown by increased urine output, as this directly reflects fluid removal, critical for heart failure management.

Choice C reason: Increased heart rate is not a direct indicator of furosemide efficacy. Diuresis reduces cardiac workload, potentially stabilizing heart rate, but urine output is the primary measure, as it confirms fluid excretion, the medication’s main action in heart failure.

Choice D reason: Weight gain indicates fluid retention, the opposite of furosemide’s goal. Effective diuresis causes weight loss due to fluid excretion. Increased urine output is the key sign, as it directly measures the diuretic’s action in reducing heart failure-related fluid overload.

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Which intervention should the nurse implement to manage a client’s fluid and electrolyte balance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with emphysema is reporting difficulty breathing and exhibiting audible wheezing. The nurse administers albuterol as prescribed for the third time within the last 12 hours. Which assessment finding warrants immediate intervention by the nurse?

Correct Answer is C

Explanation

A client with a history of heart failure is prescribed furosemide. Which assessment finding indicates the medication is effective?

Correct Answer is A

Explanation

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