A patient with congestive heart failure is at risk of excess fluid volume. Which intervention will best determine if the patient is beginning to have excess fluid volume?
Daily intake and output recordings
Daily weights
Daily blood pressure and heart rate checks
Daily CMP lab draw
The Correct Answer is B
Daily weights provide a reliable and accurate measure of fluid balance in the body. An increase in weight can indicate fluid retention and the need for further intervention. While daily intake and output recordings, blood pressure and heart rate checks, and CMP lab draws can also provide useful information, daily weights are the most effective way to monitor for excess fluid volume in this situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The client's greenish-yellow sputum with a musty odor may indicate an infection, such as pneumonia or bronchitis, which can affect the client's lung function. By auscultating bilateral breath sounds, the nurse can assess for the presence of abnormal lung sounds, such as crackles or wheezing, which may indicate further respiratory compromise.
While obtaining a blood culture for tuberculosis (option b) may be appropriate in certain circumstances, the client's sputum color and odor do not necessarily indicate tuberculosis as the cause of their respiratory symptoms.
Requesting pulmonary function studies (option c) may also be beneficial in assessing the client's lung function, but this is not the priority assessment in this situation.
Finally, while documenting the findings (option d) is an important aspect of nursing care, it is not the priority action when the client is presenting with signs of compromised lung function.
Correct Answer is D
Explanation
Explanation: The normal range of sodium (Na+) in the blood is 135-145 mEq/L. The patient's sodium level of 121 mEq/L is below the normal range, indicating a low sodium level, which is called hyponatremia.
Hyponatremia is a common electrolyte imbalance that can be caused by a variety of factors, including excessive sweating, vomiting, diarrhea, certain medications, kidney disease, and hormonal imbalances. It can cause symptoms such as nausea, headache, confusion, seizures, and coma, and it can be a medical emergency if the sodium level drops rapidly or severely.
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