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: Serum potassium of 5.0 me/L and serum sodium of 138 me/L are within normal ranges and do not reflect the expected electrolyte imbalances due to dehydration from vomiting and diarrhea.

Choice B reason: Serum potassium of 4.5 me/L and serum sodium of 140 me/L are also within normal ranges. This does not reflect the typical imbalance caused by dehydration.

Choice C reason: Serum potassium of 3.5 me/L and serum sodium of 142 me/L are normal values. They do not indicate the electrolyte disturbances expected with dehydration from vomiting and diarrhea.

Choice D reason: Serum potassium of 3.0 me/L indicates hypokalaemia (low potassium), and serum sodium of 149 me/L indicates hypernatremia (high sodium). These imbalances are expected in a client with a history of fever, vomiting, and diarrhea, as these conditions can lead to loss of potassium and concentration of sodium due to dehydration.

A. Draw air in through the nose and exhale slowly through pursed lips. B. Increase breathing rate for a full 30 seconds. C. Raise hands above the head to expand the diaphragm. D. Lay down on each side with knees bent and breathe from the abdomen.

Correct Answer is A

Explanation

Choice A reason: Drawing air in through the nose and exhaling slowly through pursed lips is a technique known as pursed-lip breathing. This method helps improve gas exchange by keeping the airways open longer during exhalation, which aids in the removal of trapped air and reduces dyspneal.

Choice B reason: Increasing the breathing rate for a full 30 seconds is not recommended for clients with emphysema. Rapid breathing can lead to hyperventilation and increased work of breathing, which can exacerbate dyspneal.

Choice C reason: Raising hands above the head to expand the diaphragm might help in some situations, but it is not as effective as pursed-lip breathing for improving gas exchange and reducing dyspneal in clients with emphysema.

Choice D reason: Laying down on each side with knees bent and breathing from the abdomen is a relaxation technique that can help some clients, but it does not specifically address the need for improved gas exchange during episodes of dyspneal.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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The nurse is caring for a client with emphysema who is mildly dyspneic after ambulation. Which instruction should the nurse provide to the client to improve gas exchange?

Correct Answer is A

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