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 C

Explanation

Choice A reason: Keeping toenails trimmed short is important for foot care, especially in clients with PAD, but it is not the highest priority.

Choice B reason: Applying a heating pad to soothe leg pain can provide temporary relief but does not address the underlying issue of PAD or reduce cardiovascular risk.

Choice C reason: Enrolling in a smoking cessation program is the highest priority. Smoking significantly exacerbates PAD and increases the risk of further cardiovascular events, including heart attacks. Quitting smoking is crucial for improving vascular health and reducing the risk of complications.

Choice D reason: Reducing intake of high saturated fats and salt is important for overall cardiovascular health but is not as immediate or impactful as smoking cessation in reducing the risk of complications from PAD and MI.

A. Elevate the head of the bed to 90 degrees. B. Monitor pulse oximetry every 2 hours. C. Determine exposure to asthmatic triggers. D. Teach proper use of a rescue inhaler.

Correct Answer is A

Explanation

Choice A reason: Elevating the head of the bed to 90 degrees is crucial for clients in respiratory distress. This position helps to maximize lung expansion, improve breathing, and alleviate respiratory effort. It provides immediate support to enhance oxygenation and ventilation.

Choice B reason: Monitoring pulse oximetry is important for assessing the client's oxygenation status but should be done continuously rather than every 2 hours in a client in respiratory distress.

Choice C reason: Determining exposure to asthmatic triggers is relevant for long-term management but not the immediate priority in an acute situation where the client is in respiratory distress.

Choice D reason: Teaching the proper use of a rescue inhaler is essential but should be done after stabilizing the client's condition. The immediate focus should be on interventions that provide rapid relief from respiratory distress.

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Naxlex Comprehensive Predictor Exams

The nurse is developing a teaching plan for a client with peripheral arterial disease (PAD) who has a history of a myocardial infarction (MI) and smokes two packs of cigarettes daily. Which instruction has the greatest priority?

Correct Answer is C

Explanation

After initializing a steroid nebulizer treatment for an asthmatic client in respiratory distress, which intervention is most important for the nurse to implement?

Correct Answer is A

Explanation

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