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 C

Explanation

A. Select upper arm as the injection site is incorrect. While the upper arm can be an appropriate site for an intradermal injection, the most common site for ID injections is the inner forearm. The choice of site depends on the procedure and provider's preferences.

B. Massage the site gently after injection is incorrect. Massaging the site after an intradermal injection can disrupt the injection, causing the medication to be dispersed under the skin rather than remaining in the dermis.

C. Ensure bevel of the needle is pointing up is the correct action. For intradermal injections, the bevel of the needle should be facing upward to ensure that the medication is injected just beneath the skin, creating a visible wheal.

D. Hold the syringe perpendicular to the skin is incorrect. For intradermal injections, the needle should be inserted at a 5-15 degree angle to the skin, not perpendicular.

A. "The healthcare provider will share this information with you." B. "I'm sorry, but your son's medical information is none of your business." C. "I can give you those results as soon as I get them back from the lab." D. "I can only give medical information to your son because he is an adult."

Correct Answer is D

Explanation

A. "The healthcare provider will share this information with you" implies that the father has the right to access the client’s information, which is incorrect unless the client has provided explicit consent.

B. "I'm sorry, but your son's medical information is none of your business" is inappropriate and dismissive. While the father does not have automatic rights to the information, the response should be respectful and professional.

C. "I can give you those results as soon as I get them back from the lab" violates the client’s privacy, as the father is not automatically entitled to this information without the client’s consent.

D. "I can only give medical information to your son because he is an adult" is correct because the client is 19 years old and legally an adult. Under privacy laws such as HIPAA, the nurse cannot share medical information with anyone, including parents, unless the client has given permission.

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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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Explanation

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Correct Answer is D

Explanation

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