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 ["A","B","D"]

Explanation

A. Streak formation along the vein is a characteristic sign of phlebitis. It indicates inflammation and possibly thrombophlebitis (inflammation with clot formation) within the vein.

B. Erythema (redness) at the insertion site is a common early sign of phlebitis. It indicates localized inflammation of the vein.

C. Blistering around the insertion site is not typically associated with phlebitis. It may suggest a severe reaction or infection, but it is not a common manifestation of phlebitis itself.

D. Warmth at the insertion site is a common sign of inflammation, including phlebitis. It indicates increased blood flow and localized inflammatory response.

E. A damp dressing over the insertion site can contribute to the risk of infection but is not a direct manifestation of phlebitis. However, it can be a contributing factor to the development of phlebitis if moisture leads to skin breakdown or infection.

A. Leaves small air bubbles in the new infusion tubing. B. Inserts the new device distal to the old IV site. C. Wears clean gloves during the new IV insertion. D. Shaves the hair on the client's skin before inserting the new IV.

Correct Answer is C

Explanation

A. Leaving small air bubbles in the new infusion tubing is incorrect. Air bubbles should be primed out of the tubing before use to prevent air embolism.

B. Inserting the new device distal to the old IV site is incorrect. The new IV site should be placed proximal to the old site to avoid complications from previous catheter use and ensure proper circulation.

C. Wearing clean gloves during the new IV insertion is correct. Clean gloves are appropriate when inserting a new short peripheral IV device. Sterile gloves are generally required for more invasive procedures, but when changing the device itself, clean gloves are sufficient.

D. Shaving the hair on the client's skin before inserting the new IV is incorrect. Shaving the skin is not recommended because it can cause small nicks that increase the risk of infection. Clipping the hair, if necessary, is the preferred method.

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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 monitoring a client's IV site. The nurse should report which of the following findings as manifestations of phlebitis? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

A nurse is assisting with supervising a newly licensed nurse replace a short-peripheral IV device for a client. Which of the following actions by the new nurse indicates an understanding of the procedure?

Correct Answer is C

Explanation

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