The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients?

Assess the patients for edema in extremities.

Ask the patients to record their intake and output.

Weigh the patients every morning before breakfast.

Measure the patients' blood pressures every 4 hours.

Answer and Explanation

The Correct Answer is C

A. Assess the patients for edema in extremities: While assessing for edema can be helpful in heart failure patients, it may not be the most effective method to monitor fluid volume status in patients at risk for dehydration, as edema may not be present in early dehydration.

B. Ask the patients to record their intake and output: Recording intake and output is important for monitoring fluid balance, but it is not as reliable as daily weight measurements. Patients may not be accurate in recording intake and output, especially in acute settings.

C. Weigh the patients every morning before breakfast: Weighing patients at the same time every day provides the most accurate and reliable measure of fluid volume status. A sudden weight gain or loss can indicate fluid retention in heart failure or dehydration, making this the most effective intervention for monitoring fluid status in both conditions.

D. Measure the patients' blood pressures every 4 hours: Blood pressure monitoring can provide some insight into fluid status, but it is not as directly indicative of fluid volume as daily weights. BP changes may not be as sensitive to small fluctuations in fluid volume.

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Correct Answer is A

Explanation

A. Renal: In respiratory acidosis, the kidneys compensate by retaining bicarbonate (HCO3-) and excreting hydrogen ions (H+), which helps to restore normal pH levels. This compensation process can take hours to days, as the renal system gradually works to balance the acid-base disturbance.

B. Endocrine: The endocrine system plays a role in regulating various body functions, but it is not responsible for compensating respiratory acidosis. While hormones like aldosterone affect fluid and electrolyte balance, they do not compensate for acid-base imbalances.

C. Respiratory: The respiratory system itself is the cause of respiratory acidosis due to inadequate ventilation and CO2 retention. The body cannot rely on the same system (respiratory) for compensation; compensation comes from the renal system instead.

D. Gastrointestinal: The gastrointestinal system does not directly compensate for respiratory acidosis. While it is involved in digestion and nutrient absorption, it does not play a significant role in regulating blood pH during acid-base imbalances.

A. Excessive thirst B. Irregular heartbeat C. Swelling of ankles D. Frightening hallucinations

Correct Answer is B

Explanation

A. Excessive thirst: Excessive thirst, polydipsia, is not the most immediate concern with a potassium level of 5.2 mEq/L. Potassium levels within this range (slightly elevated) may not directly cause excessive thirst.

B. Irregular heartbeat: Elevated potassium levels can cause dangerous cardiac arrhythmias, including irregular heartbeat. Therefore, the most important assessment is monitoring for signs of cardiac disturbances.

C. Swelling of ankles: Swelling of the ankles is more commonly associated with fluid retention or circulatory issues and is not directly linked to minor elevations in potassium levels. Although elevated potassium can affect fluid balance, it does not immediately present as swelling.

D. Frightening hallucinations: Hallucinations can be caused by a variety of factors, but they are not a direct effect of slightly elevated potassium levels. More serious symptoms like cardiac arrhythmias are a more immediate concern with abnormal potassium levels.

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The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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