quick Support- Getscreen.me sunny 5 go.getscreen.me/turbo/942218687 HESI A10:36 - MPL-LC2-12- Gets Creer X Question 38 of 85 1320798 Q Lahr 25min 33s remaining O A Lung sounds. OB Turgor. A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance? C Weight. D Blood pressure. Copyright 2024 Elsevier inc., its licensors, and contributors. All rights are reserved, including those for text and data mining. Al training, and similar technologies. Q Search Having Trouble? Contact Support Submit answer and casualize Exam Submit and Continue Show calculator ENG INTL VL380
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A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?
Lung sounds.
Turgor.
Weight.
Blood pressure.
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The Correct Answer is C
Choice A reason: Lung sounds are important to assess for signs of fluid in the lungs, such as crackles, which can occur with fluid volume overload. However, they do not directly measure fluid balance.
Choice B reason: Turgor assesses skin elasticity and hydration status, but it is not the most accurate indicator of overall fluid balance in the context of fluid volume overload.
Choice C reason: Weight is the most accurate and direct measure of fluid balance. Daily weight monitoring can track changes in fluid status, as weight fluctuations can reflect gains or losses in body fluid.
Choice D reason: Blood pressure is important to monitor, especially in clients with fluid volume issues, but it is not the most direct measure of fluid balance. Weight changes provide more precise information about fluid status.
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Correct Answer is A
Explanation
Choice A reason: Determining if the client has a sliding scale insulin prescription is crucial. A sliding scale insulin regimen can help manage elevated blood glucose levels effectively. In the case of a capillary glucose of 365 mg/dL, prompt intervention is needed to prevent hyperglycaemia-related complications, and insulin administration is the most appropriate immediate action.
Choice B reason: Stopping the infusion until the healthcare provider is notified may not be the best immediate action. While it is essential to address the hyperglycaemia, halting the parenteral nutrition infusion can affect the client's overall nutritional and fluid balance. The focus should be on managing the glucose levels promptly.
Choice C reason: Assessing the client's urinary output for the previous 24 hours is important for monitoring overall fluid status and kidney function, but it does not directly address the immediate need to manage the elevated glucose levels.
Choice D reason: Reviewing the client's record for a history of diabetes mellitus can provide valuable information for long-term management and understanding the client's baseline glucose control. However, it is not the most urgent action in response to an acutely elevated capillary glucose level. Immediate intervention with insulin is needed to address the hyperglycaemia.
Correct Answer is D
Explanation
Choice A reason: Lethargy and lack of appetite are symptoms that might indicate hypothyroidism or an insufficient dosage of levothyroxine. These symptoms are not typically associated with a dosage that is too high.
Choice B reason: Bradycardia and constipation are also indicative of hypothyroidism or an inadequate dosage of levothyroxine. These symptoms suggest a need for a higher dosage rather than indicating that the current dosage is too high.
Choice C reason: Muscle cramping and dry, flushed skin can be associated with electrolyte imbalances or dehydration, but they are not specific symptoms of an excessive dosage of levothyroxine.
Choice D reason: Palpitations and shortness of breath are signs of hyperthyroidism, which can occur if the dosage of levothyroxine is too high. These symptoms indicate that the client's metabolism is excessively stimulated, leading to cardiovascular strain and respiratory distress. It is crucial for the nurse to monitor these symptoms and adjust the medication dosage accordingly.
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