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. A patient who lost 2 liters of blood during surgery: This is the most acute and severe form of hypovolemia due to significant blood loss, requiring immediate fluid replacement and hemodynamic monitoring.

B. A patient who received 6 liters of IV fluid: This patient is at risk for hypervolemia, not hypovolemia, due to fluid overload.

C. A patient with UTI on PO meds: While dehydration may occur, it is typically mild and does not cause hypovolemia.

D. A patient with congestive heart failure: CHF usually leads to fluid retention, making hypovolemia unlikely unless there are other complicating factors.

A. Elevated blood pressure B. Negative Chvostek sign C. Constipation D. Tetany

Correct Answer is D

Explanation

A. Elevated blood pressure: Hypocalcemia is more likely to cause low blood pressure due to its effect on vascular tone and cardiac contractility, not elevated blood pressure.

B. Negative Chvostek sign: A negative Chvostek sign would be expected in clients with normal calcium levels. A positive Chvostek sign (twitching of the facial muscles when tapped) is a sign of hypocalcemia.

C. Constipation: Hypocalcemia does not typically cause constipation. In fact, hypercalcemia can lead to constipation.

D. Tetany: Tetany, which involves muscle cramps and spasms, is a common manifestation of hypocalcemia. It occurs due to increased neuromuscular excitability when calcium levels are low.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a group of patients. Which patient is at highest risk for hypovolemia?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has a calcium level of 8 mg/dL (9.0-10.5 mg/dL). Which of the following manifestations should the nurse expect?

Correct Answer is D

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?

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The nurse is preparing to start an IV on a newly admitted patient. Which action by the nurse places the patient at risk for infection?

A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect?

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A nurse is collecting data from a client who has a calcium level of 12 mg/dL (9-10.5 mg/dL). Which of the following manifestations should the nurse expect?

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