A client with fluid overload receives a prescription for fluid restriction of 1 liter/day and a diuretic. Which action(s) should the nurse perform to best evaluate the effectiveness of the treatment? Select all that apply.

Calculate the intake and output.

Assess pulse rate.

Monitor the temperature.

Checking for orthostatic hypotension.

Obtain a daily weight.

Answer and Explanation

Correct Answer : A,E

A. Calculate the intake and output: Measuring intake and output directly reflects fluid balance, making it one of the most reliable ways to determine if fluid restriction and diuretics are effective. Tracking fluid intake compared to urine output helps assess reduction in fluid overload.

B. Assess pulse rate: While monitoring pulse rate is part of routine assessment, it does not provide a clear picture of whether fluid overload is improving. Changes in pulse may occur with dehydration, arrhythmias, or other conditions, but it is not a primary measure of fluid balance.

C. Monitor the temperature: Body temperature is important for identifying infection or inflammation but does not indicate fluid status. Monitoring temperature would not help evaluate whether fluid restriction and diuretic therapy are relieving fluid overload.

D. Checking for orthostatic hypotension: Orthostatic changes can suggest hypovolemia or dehydration but are less useful for measuring the gradual effectiveness of fluid restriction. They may be monitored if over-diuresis is suspected, but they are not the best evaluation tool.

E. Obtain a daily weight: Daily weight is one of the most accurate indicators of fluid balance. A decrease in weight reflects effective removal of excess fluid, as even small weight changes can indicate significant fluid gain or loss in the body.

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Correct Answer is A

Explanation

A. Wear closed-toe shoes that are comfortable and fit well: Proper footwear is essential to prevent foot injuries, ulcers, and infections in clients with diabetes, especially because neuropathy can reduce sensation. This response indicates understanding of a key self-care measure.

B. Check blood sugar levels every four to six hours every day: Blood glucose monitoring frequency should be individualized based on treatment regimen, activity, and glycemic control. A blanket schedule every four to six hours may not be appropriate for all clients.

C. Restrict alcoholic beverages to no more than 1 to 2 per week: Alcohol guidelines should be individualized, and alcohol can affect blood glucose unpredictably. Limiting intake is important, but this statement alone does not fully reflect diabetes management understanding.

D. Obtain an A1C blood test every year to monitor glucose control: The recommended frequency for A1C testing is usually every 3 months when starting treatment or if therapy changes, and every 6 months for stable control.

A. Palpate the client's suprapubic area for distention. B. Instruct in effective techniques to cleanse the glans penis. C. Obtain a urine specimen for culture and sensitivity. D. Advise the client to maintain a voiding diary for one week.

Correct Answer is A

Explanation

A. Palpate the client's suprapubic area for distention: Palpating for bladder distention helps determine if urinary retention is present, which is common in older men with possible benign prostatic hyperplasia (BPH). Assessing retention is a priority because unresolved urinary obstruction can lead to hydronephrosis or kidney damage.

B. Instruct in effective techniques to cleanse the glans penis: Proper hygiene is important for preventing infection, especially in uncircumcised males, but it does not address the client’s primary problem of urinary retention and obstructive symptoms.

C. Obtain a urine specimen for culture and sensitivity: While urinary tract infections can occur in clients with urinary retention, the presenting symptoms here are more indicative of obstruction due to prostate enlargement. A culture may be ordered later, but not the first step.

D. Advise the client to maintain a voiding diary for one week: A voiding diary provides helpful long-term information about urinary patterns, but it does not address the acute issue of a bladder that may be distended and retaining urine.

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A client with fluid overload receives a prescription for fluid restriction of 1 liter/day and a diuretic. Which action(s) should the nurse perform to best evaluate the effectiveness of the treatment? Select all that apply.

Nursing Test Bank

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The nurse is providing teaching to a client newly diagnosed with type 2 diabetes mellitus about disease management. Which response by the client indicates understanding?

Correct Answer is A

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Explanation

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