A patient with multiple draining wounds is admitted for hypovolemia. Which assessment would be the most accurate way for the nurse to evaluate fluid balance?
Edema presence
Skin turgor
Urine output
Daily weight
The Correct Answer is D
Choice A reason: This statement is false. Edema is a sign of fluid overload, not fluid deficit. Edema occurs when fluid accumulates in the interstitial space due to increased capillary hydrostatic pressure or decreased plasma oncotic pressure. Edema is more common in patients with heart failure, liver disease, or kidney disease¹.
Choice B reason: This statement is false. Skin turgor is a measure of skin elasticity and hydration. It can be affected by factors such as age, skin condition, and ambient temperature. Skin turgor is not a reliable indicator of fluid balance, as it can be normal in patients with mild to moderate hypovolemia².
Choice C reason: This statement is false. Urine output is a measure of kidney function and fluid excretion. It can be influenced by factors such as fluid intake, diuretics, hormones, and renal diseases. Urine output is not a sensitive indicator of fluid balance, as it can be normal or even increased in patients with hypovolemia due to compensatory mechanisms.
Choice D reason: This statement is true. Daily weight is a measure of body mass and fluid status. It can reflect changes in fluid balance more accurately than other methods, as long as the weight is measured at the same time, on the same scale, and with the same clothing each day. A decrease in weight can indicate fluid loss due to hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
Choice A reason: Foot inspection is not an annual/yearly screening, but a daily self-care practice for people with diabetes. Foot inspection involves checking the feet for any signs of injury, infection, or ulceration, such as cuts, blisters, redness, swelling, or drainage. Foot inspection can help prevent or detect foot problems, such as neuropathy, ischemia, or infection, which can lead to amputation if left untreated. The nurse should teach Jo how to inspect his feet every day, and how to care for his feet, such as washing, drying, moisturizing, trimming nails, and wearing proper footwear.
Choice B reason: Serum creatinine (Cr) is an annual/yearly screening for people with diabetes. Serum creatinine is a blood test that measures the level of creatinine, a waste product that is filtered by the kidneys. Serum creatinine can indicate the kidney function, and detect kidney damage or disease, which is a common complication of diabetes. The nurse should explain to Jo that he needs to have his serum creatinine checked every year, and that he should keep his blood glucose and blood pressure under control, as these are the main risk factors for kidney problems.
Choice C reason: Chest X-ray is not an annual/yearly screening for people with diabetes, unless they have symptoms or risk factors for lung diseases, such as tuberculosis, pneumonia, or cancer. Chest X-ray is an imaging test that uses X-rays to produce pictures of the lungs and the chest cavity. Chest X-ray can help diagnose or monitor lung conditions, such as infections, inflammations, or tumors. The nurse should ask Jo about his history of smoking, exposure to environmental pollutants, or respiratory symptoms, such as cough, shortness of breath, or chest pain, and refer him to a doctor if he needs a chest X-ray.
Choice D reason: White blood cell count (WBC) is not an annual/yearly screening for people with diabetes, unless they have signs or risk factors for infections, such as fever, wounds, or immunosuppression. White blood cell count is a blood test that measures the number and types of white blood cells, which are the cells that fight infections and inflammation. White blood cell count can help diagnose or monitor infections, such as bacterial, viral, or fungal infections, or immune disorders, such as allergies, autoimmune diseases, or cancers. The nurse should assess Jo for any signs of infection, such as fever, chills, malaise, or pus, and advise him to seek medical attention if he has any.
Correct Answer is C
Explanation
Choice A reason: This statement is false. Nephropathy is a term that refers to any disease or damage of the kidneys. Acetaminophen overdose can cause nephropathy, but it is not the most serious toxic effect. Nephropathy can manifest as reduced urine output, increased blood urea nitrogen and creatinine levels, and electrolyte imbalance.
Choice B reason: This statement is false. Tachycardia is a term that refers to a fast heart rate, usually more than 100 beats per minute. Acetaminophen overdose can cause tachycardia, but it is not the most serious toxic effect. Tachycardia can be a sign of dehydration, fever, pain, or anxiety.
Choice C reason: This statement is true. Liver dysfunction is the most serious toxic effect of acute acetaminophen overdose. Acetaminophen is metabolized by the liver and can produce a toxic byproduct that damages the liver cells. Liver dysfunction can manifest as jaundice, abdominal pain, nausea, vomiting, and elevated liver enzymes.
Choice D reason: This statement is false. Central nervous system depression is a term that refers to a reduced level of consciousness, alertness, and responsiveness. Acetaminophen overdose can cause central nervous system depression, but it is not the most serious toxic effect. Central nervous system depression can be a sign of hypoxia, hypoglycemia, or drug intoxication.
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