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.

Here's the edited text with the instructions applied:

Answer and Explanation

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 D

Explanation

Choice A reason: Pacing the client's care to provide periods of rest is important for managing fatigue and preventing overexertion. However, it is not the first action the nurse should take in this situation. Monitoring vital signs is crucial to assess the client's current condition and detect any immediate complications.

Choice B reason: Making arrangements for radioactive iodine therapy is a treatment option for hyperthyroidism. However, this is not the first action the nurse should take. The nurse needs to assess the client's condition and stabilize any immediate issues before considering long-term treatment options.

Choice C reason: Administering a beta-adrenergic blocking agent can help manage symptoms such as a racing heartbeat and nervousness. While this may be part of the treatment plan, it is not the first action the nurse should take. Monitoring vital signs is essential to determine the appropriate interventions.

Choice D reason: Monitoring the client's vital signs frequently is the first action the nurse should take. This helps assess the client's current condition, detect any immediate complications, and guide further interventions. It is crucial to ensure the client's stability before implementing other care measures.

A. Apply soft restraints to all extremities. B. Remove objects that could cause injury. C. Place pillows around the client's head. D. Administer oxygen per nasal cannula.

Correct Answer is B

Explanation

Choice A reason: Applying soft restraints to all extremities is not appropriate during a seizure as it can increase the risk of injury. The priority is to ensure the client's safety by preventing injury without restraining them.

Choice B reason: Removing objects that could cause injury is crucial. During a seizure, the client may move unpredictably, and any nearby objects could pose a risk of harm. Clearing the area ensures the client has a safe space to have the seizure without additional hazards.

Choice C reason: Placing pillows around the client's head can provide some protection, but it is not as immediately effective or necessary as removing potentially harmful objects from the surrounding area. Ensuring a clear and safe environment is the primary concern.

Choice D reason: Administering oxygen per nasal cannula is not the first priority during a seizure. While maintaining oxygenation is important, the immediate focus should be on ensuring the client's physical safety by removing dangerous objects. Once the seizure subsides, appropriate respiratory support can be provided if needed.

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