A client admited with heart failure requires careful monitoring of his ﬂuid status. Which method will provide the nurse with the best indication of the client’s ﬂuid status?

daily electrolyte monitoring

daily weights

output measurements

daily BUN and serum creatinine monitoring

Answer and Explanation

The Correct Answer is B

Fluid retention is a common complication in heart failure, and monitoring the client's ﬂuid status is crucial to manage the condition eﬀectively. Daily weights are an essential component of monitoring ﬂuid status and are the most sensitive and practical method to detect changes in the client's ﬂuid status. Weight gain is a reliable indicator of ﬂuid retention, and even small increases in weight can indicate the need for changes in the client's treatment plan.

Although electrolyte monitoring (option a), output measurements (option c), and daily BUN and serum creatinine monitoring (option d) can provide valuable information about the client's ﬂuid status, they are not as sensitive or practical as daily weights. Electrolyte monitoring can help detect changes in ﬂuid balance, but it does not provide a direct indication of ﬂuid status. Output measurements can indicate ﬂuid loss, but they do not provide an accurate assessment of ﬂuid retention. BUN and serum creatinine monitoring can detect changes in renal function, but they are not specific to ﬂuid status.

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Correct Answer is D

Explanation

Explanation: The normal range of sodium (Na+) in the blood is 135-145 mEq/L. The patient's sodium level of 121 mEq/L is below the normal range, indicating a low sodium level, which is called hyponatremia.

Hyponatremia is a common electrolyte imbalance that can be caused by a variety of factors, including excessive sweating, vomiting, diarrhea, certain medications, kidney disease, and hormonal imbalances. It can cause symptoms such as nausea, headache, confusion, seizures, and coma, and it can be a medical emergency if the sodium level drops rapidly or severely.

A. Chart the reading at 91%, this is normal for a COPD patient. B. Place a non-rebreather on the patient with high ﬂow oxygen. C. Call the doctor if the patient is declining. D. Sit the patient up and have them breathe deep.

Correct Answer is D

Explanation

Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.

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A client admited with heart failure requires careful monitoring of his ﬂuid status. Which method will provide the nurse with the best indication of the client’s ﬂuid status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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