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 ["125"]

Explanation

To calculate the rate at which the IV pump should be set to deliver the prescribed volume of intravenous fluids,

Divide the total volume of fluids (3,000 mL) by the number of hours over which they are to be administered (24 hours). This calculation gives you 125 mL/hr.

Therefore, the nurse should set the IV pump to deliver 125 mL of fluid per hour to meet the 24-hour requirement.

A. Hold the syringe at a 20° angle to the client's skin. B. Draw up 0.5 mL of purified protein derivative (PPD) from the vial. C. Place a 1 in needle on the syringe. D. Hold the skin taut at the chosen site with the nondominant hand before inserting the needle.

Correct Answer is D

Explanation

D. Holding the skin taut helps stabilize the area and ensures that the needle penetrates the skin smoothly and at the correct angle. This also helps prevent the needle from going too deep or slipping out of the site during injection.

A. The syringe should be held at a 5 to 15-degree angle to the client's skin, not 20 degrees.

B. For a tuberculin skin test (PPD test), typically 0.1 mL (one-tenth of a milliliter) of PPD is injected intradermally. This is a very small amount compared to 0.5 mL.

C. The length of the needle for an intradermal injection is typically shorter than 1 inch, usually around 3/8 to 5/8 inches (10-16 mm). Using a longer needle may increase the risk of inserting the needle too deeply, potentially leading to subcutaneous rather than intradermal injection.

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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

A nurse is assisting with care of a client who has a prescription for 3,000 mL of intravenous fluids over the next 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number)

Correct Answer is ["125"]

Explanation

A nurse is preparing to administer an intradermal injection for a client who requires a tuberculin skin test. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

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