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 A

Explanation

A. Cardiac dysrhythmias: Hypokalemia impairs cardiac muscle function, potentially leading to arrhythmias such as ventricular tachycardia or premature ventricular contractions.

B. Hypoglycemia: Potassium does not directly cause hypoglycemia; its imbalance more commonly affects cardiac and neuromuscular function.

C. Hyperreflexia: Hypokalemia usually causes muscle weakness and diminished reflexes (hyporeflexia), not hyperreflexia.

D. Increased appetite: Hypokalemia does not typically affect appetite.

A. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution. B. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution. C. Notify the physician D. Check for kinking of the tubing or a closed clamp.

Correct Answer is D

Explanation

A. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution: This may be necessary later if the occlusion is not resolved by troubleshooting, but the first action should be to check the tubing and clamp for any obstructions.

B. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution: This is not appropriate as an initial action. Heparin flushes are generally used for maintaining patency in central lines and are not indicated for occlusions caused by tubing issues.

C. Notify the physician: While important if the issue persists, this is not the first action. The nurse should attempt to resolve the problem independently first.

D. Check for kinking of the tubing or a closed clamp: This is the first action the nurse should take. Most occlusions are due to kinking in the tubing or a closed clamp, and resolving this issue may immediately restore the flow.

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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 reviewing the laboratory results of a client who is taking a loop diuretic and notes the client's potassium level is 3.0 mEq/L (3.5-5 mEq/L). Which of the following physiological responses should the nurse expect related to the client's hypokalemia?

Correct Answer is A

Explanation

The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?

Correct Answer is D

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?

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The nurse is reviewing laboratory results for a group of patients. Which value should be of most concern to the nurse?

A nurse is collecting data from a client who has dehydration. Which of the following findings should the nurse expect?

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