For a patient who is experiencing an ECV excess, the nurse plans to determine the fluid status. The best way for the nurse to determine the fluid balance for the patient is to:

obtain diagnostic test results

weigh the patient daily

monitor IV fluid intake

assess vital signs

Answer and Explanation

The Correct Answer is B

B. Daily weight measurements are a practical and effective method to assess fluid balance. Changes in weight can reflect fluid retention or loss. Daily weighing is particularly useful for monitoring fluid status in patients with known or suspected fluid excess. It helps detect trends over time and guides adjustments in fluid management.

A. While diagnostic tests are crucial for assessing underlying causes and complications of fluid imbalance, they do not directly provide a real-time assessment of fluid balance or volume overload.

C. Monitoring IV fluid intake provides information on the amount of fluid input but does not directly indicate how the patient's body is handling or retaining that fluid. It complements other methods like daily weight measurements.

D. Vital signs are essential for assessing the hemodynamic status and response to fluid therapy but are not specific enough to quantify fluid balance or detect mild fluid excess without other signs.

Nursing Test Bank

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Correct Answer is ["50"]

Explanation

To calculate the flow rate in gtt/min, the total volume (400 mL) should be divided by the total time in minutes (8 hours x 60 minutes/hour = 480 minutes). This gives the mL/min.

Then, multiply the mL/min by the drop factor (60 gtt/mL) to get the gtt/min. So, the calculation would be (400 mL / 480 min) x 60 gtt/mL = 50 gtt/min.

Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.

A. Dispose of used razors in wastebaskets. B. Replace sharps containers when they are full. C. Use two hands to recap a needle after administering a medication. D. Break needles on syringes before disposal.

Correct Answer is B

Explanation

B. Sharps containers should be replaced when they are 3/4 full to prevent overfilling, which could increase the risk of needlesticks when trying to dispose of sharps. Ensuring sharps containers are not overfilled helps maintain a safe environment by reducing the risk of accidental puncture injuries during disposal.

A. Used razors should be disposed of in puncture-resistant sharps containers, not in regular wastebaskets. Sharps containers are specifically designed to safely contain sharp objects to prevent accidental injuries.

C. Using two hands to recap a needle is unsafe and increases the risk of accidental needlestick injuries. It's important to educate healthcare workers to avoid recapping needles whenever possible.

D. Breaking needles before disposal is unsafe and increases the risk of injury. Needles should be disposed of intact in a puncture-resistant sharps container.

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For a patient who is experiencing an ECV excess, the nurse plans to determine the fluid status. The best way for the nurse to determine the fluid balance for the patient is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["50"]

Explanation

A nurse is assisting with teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

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