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
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
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
D. Blurred vision is a known adverse effect of metoclopramide. It can occur due to its effects on the central nervous system, including potential effects on visual processing. Patients should be informed about this potential side effect, and vision should be monitored periodically.
A. Metoclopramide can cause drowsiness or sedation, especially at higher doses or in susceptible individuals. Monitoring for sedation is important to ensure patient safety and adjust dosing as needed.
B. Urinary retention: Although less common, metoclopramide has been associated with urinary retention. Patients should be monitored for signs and symptoms of urinary difficulty or retention, especially if they have pre-existing urinary issues.
C. Hypertension: Metoclopramide can occasionally lead to an increase in blood pressure, particularly in patients who are predisposed to hypertension or have other cardiovascular risk factors. Blood pressure monitoring is important during treatment.
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