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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Assisting with mobility and fall prevention is critical in Parkinson’s disease, as bradykinesia and rigidity increase fall risk. Physical therapy and assistive devices enhance safety, reducing injury risk, making this the priority intervention to maintain functional independence and prevent fractures.
Choice B reason: High-protein meals may interfere with levodopa absorption in Parkinson’s, worsening symptoms. Mobility assistance is the priority, as falls are a leading cause of injury, requiring immediate intervention to ensure safety, making dietary protein secondary to physical support.
Choice C reason: Restricting fluid intake is inappropriate, as hydration prevents constipation in Parkinson’s. Mobility and fall prevention are critical, as motor symptoms increase injury risk. Assisting with mobility addresses the primary functional challenge, making fluid restriction irrelevant to priority care.
Choice D reason: Promoting social isolation worsens depression in Parkinson’s, a common comorbidity. Mobility assistance is the priority, as falls due to motor impairment are a significant risk, requiring immediate intervention to ensure safety, making social isolation counterproductive to care.
Correct Answer is B
Explanation
Choice A reason: Administering an antacid relieves epigastric pain but is premature without assessing pain characteristics. Pain in peptic ulcer disease may indicate complications like perforation, requiring urgent evaluation. Assessment guides whether antacids or other interventions are appropriate, prioritizing patient safety.
Choice B reason: Assessing pain characteristics (e.g., location, intensity, radiation) is the first step, as epigastric pain in peptic ulcer disease may signal complications like bleeding or perforation. This data guides interventions, ensuring timely management of potentially life-threatening conditions, making it the priority action.
Choice C reason: Checking NSAID use identifies ulcer triggers but is secondary to pain assessment. Pain characteristics determine urgency, as severe or radiating pain may indicate perforation, requiring immediate action. Assessment provides critical data before investigating contributing factors like medication history.
Choice D reason: Obtaining a stool sample for occult blood detects gastrointestinal bleeding but is not the first step. Assessing pain characteristics identifies urgent complications like perforation, guiding whether diagnostic tests or interventions are needed, making pain assessment the initial priority.
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