A nurse measures a patient’s 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse do with the information?
Report the exact milliliter of intake to the physician’s office nurse.
Compare the total intake and output of fluids for the 24 hours.
Compare the patient’s intake with the normal range of adult fluid intake.
Ensure the information is included in the verbal end-of-shift report.
The Correct Answer is B
Choice A reason: Reporting only the exact intake to the physician’s nurse is incomplete, as fluid status requires balancing intake with output. Intake alone does not indicate hydration or overload, risking misinformed decisions. Comparing intake and output provides a full picture, per fluid balance assessment principles.
Choice B reason: Comparing total intake and output over 24 hours accurately assesses fluid status, as it reveals imbalances like dehydration (output > intake) or retention (intake > output). This guides interventions, ensuring proper fluid management, aligning with physiological monitoring and clinical assessment standards.
Choice C reason: Comparing intake to a normal range is useful but insufficient without output data. Normal intake varies, and fluid status depends on balance. This approach misses output-related issues like oliguria, reducing its accuracy for assessing hydration, per fluid and electrolyte management guidelines.
Choice D reason: Including intake in verbal reports is important but does not directly assess fluid status. Comparison of intake and output is needed to evaluate balance, guiding clinical decisions. Reporting alone risks overlooking imbalances, per nursing documentation and fluid assessment protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Stating fats are mostly from animal sources is inaccurate, as plant sources (e.g., oils, nuts) also provide significant fats. A low-fat diet reduces cardiovascular risk by limiting saturated and trans fats, which raise LDL cholesterol. This statement oversimplifies fat sources, ignoring plant-based fats like olive oil, which are beneficial, making it incorrect.
Choice B reason: Unsaturated fats, including monounsaturated and polyunsaturated, are primarily from plant sources (e.g., avocados, fish), not animal sources. These fats lower LDL cholesterol, benefiting cardiovascular health. The statement is incorrect, as a low-fat diet encourages unsaturated fats over saturated, which are animal-derived, making this misinformation for dietary education.
Choice C reason: Trans fats, found in processed foods, raise LDL and lower HDL cholesterol, increasing cardiovascular risk. Guidelines recommend keeping trans fat below 7% of total calories to minimize atherosclerosis. This is critical for a low-fat diet, as trans fats disrupt lipid metabolism and endothelial function, making this the correct information to share with the patient.
Choice D reason: Polyunsaturated fats, like omega-3s, should not be limited to less than 7% of calories, as they reduce LDL and inflammation, benefiting heart health. A low-fat diet encourages these fats over trans or saturated fats. This statement is incorrect, as polyunsaturated fats support cardiovascular and metabolic health, not requiring such strict limitation.
Correct Answer is B
Explanation
Choice A reason: Florence Nightingale founded modern nursing and improved hospital sanitation but did not establish the U.S. Red Cross. Her work focused on nursing education and patient care standards, impacting healthcare systems globally. The Red Cross, a humanitarian organization, was established in the U.S. by Clara Barton, making Nightingale incorrect for this achievement.
Choice B reason: Clara Barton established the American Red Cross in 1882, providing disaster relief and wartime aid. Her work involved organizing volunteer efforts to support medical care and supplies, addressing physiological needs like wound care and nutrition during crises. Barton’s leadership formalized humanitarian aid in the U.S., making her the correct pioneer for this milestone.
Choice C reason: Dorothea Dix advocated for mental health reform and improved conditions for the mentally ill but did not found the Red Cross. Her efforts focused on institutional reforms, not disaster relief or wartime medical support. Clara Barton’s establishment of the Red Cross addressed acute humanitarian needs, making Dix incorrect for this role.
Choice D reason: Jane Addams founded Hull House and focused on social reform, not the Red Cross. Her work addressed community health and social disparities, not organized disaster or wartime relief. Clara Barton’s Red Cross provided medical and humanitarian aid, distinct from Addams’ social work, making Addams incorrect for this achievement.
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