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 ["D","E"]

Explanation

A. Notify the client's next of kin prior to surgery is not appropriate unless the client provides explicit consent. The nurse must respect the client's autonomy and confidentiality.

B. Encourage the client to execute a will that identifies a guardian for her children is outside the nurse's role. While the client’s family arrangements are important, this is not directly relevant to the surgical admission process.

C. Flag the client's record with "do not resuscitate" is not appropriate unless the client has completed the necessary documentation, such as an advance directive or physician orders for life-sustaining treatment (POLST).

D. Document the client's statement on the admission form is essential to ensure the healthcare team is aware of the client’s expressed wishes.

E. Explain the benefit of executing an advanced directive is appropriate because it informs the client about formalizing their wishes to avoid potential confusion during medical care.

A. Capillary refill time is 2 seconds. B. 2+ edema of fingers and hands. C. Blood pressure is 142/88 mm Hg. D. Radial pulse volume is 3+.

Correct Answer is B

Explanation

A. Capillary refill time is 2 seconds is within the normal range and is unlikely to interfere with the pulse oximeter reading.

B. 2+ edema of fingers and hands most likely contributes to the low oxygen saturation reading. Edema can impair the accuracy of a pulse oximeter by affecting the transmission of light through the tissues, leading to erroneous readings.

C. Blood pressure is 142/88 mm Hg is mildly elevated but does not directly affect the pulse oximeter's ability to measure oxygen saturation.

D. Radial pulse volume is 3+ indicates a strong pulse and does not interfere with the functionality of the pulse oximeter.

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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

Correct Answer is ["D","E"]

Explanation

The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

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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?