Which is the most reliable method for monitoring improvement when restoring fluid balance?

Vital signs

skin turgor

Daily input and output

Daily weights

Answer and Explanation

The Correct Answer is D

A. Vital signs: Vital signs can reflect changes in fluid status, but they are not always sensitive to small shifts in fluid balance and can be affected by many other factors like medications.

B. Skin turgor: Skin turgor can be useful for assessing dehydration but is not a reliable indicator for tracking fluid balance over time, especially in older adults where skin elasticity naturally declines.

C. Daily input and output: Monitoring intake and output is useful, but it is not the most reliable for evaluating overall fluid balance, especially in cases of insensible loss or shifts in third spaces.

D. Daily weights: Weighing the patient daily is the most reliable method for monitoring fluid balance because it directly reflects changes in fluid retention or loss, particularly in acute or chronic conditions like heart failure or dehydration.

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Correct Answer is ["100"]

Explanation

To calculate the IV flow rate, the following formula is used:

Flowrate(gtt/min) = Volume /Time× Dropfactor(gtt/mL)

Given:

Volume = 100 mL
Time = 60 minutes
Drop factor = 60 gtt/mL

Flowrate(gtt/min)= 10060× 60

=1.67×60

=100gtt/min (rounded to the nearest whole number)

A. Hematoma B. Phlebitis C. Speed Shock D. Thrombosis

Correct Answer is B

Explanation

A. Hematoma: A hematoma typically results from bleeding into the tissue, causing swelling and bruising at the infusion site, but it doesn't usually cause warmth or pain in the same way as phlebitis.

B. Phlebitis: Phlebitis is inflammation of the vein, commonly caused by an IV catheter or medication, and it often presents with redness, warmth, pain, and swelling at the infusion site. It is the most likely complication here.

C. Speed Shock: Speed shock occurs when a medication or fluid is administered too rapidly, causing symptoms such as dizziness, chest tightness, and hypotension, not localized symptoms like redness and pain at the infusion site.

D. Thrombosis: Thrombosis refers to the formation of a blood clot within a vein, which can cause swelling, warmth, and discomfort but would also likely involve more significant blockage and would be associated with reduced blood flow, not just localized redness and pain.

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Which is the most reliable method for monitoring improvement when restoring fluid balance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer dextrose 5% in water IV to infuse at 100 mL/60 min. The drop factor on the manual IV tubing is 60 gtt/mL. The nurse should set the IV flow rate to deliver how many gtt/min? (Round to the nearest whole number.)

Correct Answer is ["100"]

Explanation

An 87-year-old patient recovering from abdominal surgery has a continuous intravenous infusion to supply nutrients and antibiotics. What complication should you suspect when signs and symptoms of redness, warmth, and pain at the infusion site are reported?

Correct Answer is B

Explanation

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