A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

Turgor.

Blood pressure.

Weight.

Lung sounds.

Answer and Explanation

The Correct Answer is C

A. Turgor is not a reliable indicator of fluid balance in clients with fluid volume overload, as it is more commonly used to assess dehydration.

B. Blood pressure is affected by fluid volume but is not a direct or specific measure of fluid balance. Other factors, such as medication or underlying conditions, can influence blood pressure.

C. Weight is the most accurate and sensitive indicator of fluid balance. A change in weight directly correlates with fluid retention or loss, making it the preferred method for evaluating fluid balance.

D. Lung sounds can indicate fluid overload if crackles are present, but they are not a quantitative measure of fluid balance and do not provide ongoing assessment of fluid changes.

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Correct Answer is B

Explanation

A. Whether they contain pulp or fruit is unnecessary to assess because flavored gelatin is typically free of pulp or fruit. The concern lies more with the appropriateness of the ingredients as clear liquids.

B. The color and flavor of gelatin used is the correct response because some colored gelatins (e.g., red or purple) can mimic blood if vomiting occurs, potentially leading to misinterpretation of the child’s condition. The nurse should ensure that the parent uses neutral or light-colored gelatin (e.g., yellow or clear).

C. How many popsicles are available is not relevant to the appropriateness of the popsicles as a clear liquid or their potential effects on the child’s condition.

D. If the popsicles are completely frozen is not significant as long as the popsicles are made from appropriate clear liquids.

A. Provide a box of tissues for the client to use when coughing. B. Obtain face masks for staff to wear upon entering the room. C. Assist the client in changing into a fresh hospital gown. D. Teach the client to cover the mouth with hands when coughing.

Correct Answer is B

Explanation

A. Provide a box of tissues for the client to use when coughing is a helpful action for promoting hygiene and comfort. However, this does not address the potential risk of infection transmission to staff and others in the room.

B. Obtain face masks for staff to wear upon entering the room is the most appropriate action. The client is coughing, and non-productive coughing can still release droplets that may carry infectious agents. Wearing face masks helps protect staff and other individuals from potential exposure to airborne pathogens.

C. Assist the client in changing into a fresh hospital gown is a considerate action but does not directly address the immediate concern of infection control. The priority here is preventing the spread of potential infectious particles.

D. Teach the client to cover the mouth with hands when coughing is incorrect. The client should cover their cough with their elbow or a tissue, not with their hands, to prevent spreading germs. Teaching this technique is important but does not address the immediate need for protective measures for staff.

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A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

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Naxlex Comprehensive Predictor Exams

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