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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["300"]
Explanation
Calculation:
Total volume of the medication solution to be infused = 300 mL.
Infusion time = 60 minutes.
- Convert the infusion time from minutes to hours.
Infusion time in hours = 60 minutes / 60 minutes/hour
= 1 hour.
- Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Infusion time (hr)
= 300 mL / 1 hour
= 300 mL/hour.
Correct Answer is B
Explanation
A. Regulating cardiac enzymes: Potassium does not directly regulate cardiac enzymes. Its influence on the heart is more about maintaining the electrical potential across cell membranes, which is crucial for the heart's rhythm and contractility.
B. Maintaining normal nerve and muscle activity: Potassium is crucial for maintaining normal nerve and muscle function. It helps generate electrical impulses in cells, particularly in muscles and nerves, including the heart muscle.
C. Regulating kidney function: While potassium levels are regulated by the kidneys, potassium itself does not regulate kidney function. The kidneys help maintain potassium balance in the body by excreting or conserving it.
D. Stimulating the excretion or retention of chloride: Potassium does not regulate chloride excretion or retention.The excretion or retention of chloride is often linked to the movement of sodium and other ions to maintain electrical neutrality and fluid balance.
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