The nurse is caring for a patient with a history of chronic kidney disease who was admitted with hypervolemia. As part of discharge planning, which instruction will the nurse provide to help the patient accurately monitor their fluid balance?

Monitor your blood pressure weekly.

Limit your fluid intake to 3 liters per day.

Weigh yourself at the same time each day.

Increase your daily sodium intake to balance your fluids.

Answer and Explanation

The Correct Answer is C

Choice A reason: Monitoring blood pressure weekly is important but does not directly help the patient accurately monitor their fluid balance. Daily weight monitoring provides more immediate feedback on fluid status changes.

Choice B reason: Limiting fluid intake to 3 liters per day may be appropriate for some patients but does not directly help the patient monitor their fluid balance. Accurate fluid monitoring involves tracking intake, output, and changes in body weight.

Choice C reason: Weighing yourself at the same time each day is crucial for accurately monitoring fluid balance. Daily weights provide consistent and immediate information about changes in fluid status, which is essential for managing hypervolemia in patients with chronic kidney disease.

Choice D reason: Increasing daily sodium intake is not appropriate for patients with hypervolemia, as it can lead to further fluid retention and worsen the condition. The focus should be on reducing sodium intake and monitoring fluid balance.

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Correct Answer is C

Explanation

Choice A reason: Shaking the MDI before use is correct technique as it ensures that the medication is properly mixed.

Choice B reason: Exhaling before using the MDI is proper technique as it prepares the lungs for inhalation of the medication.

Choice C reason: Inspiring rapidly when dispensing the medication is incorrect because it can cause the medication to deposit in the mouth or throat rather than reaching the lungs.

Choice D reason: Holding the breath for 10 seconds after inhaling the medication is correct technique as it allows the medication to settle in the lungs.

A. Check the patient's blood pressure before and after the IV administration. B. Ensure the dialysis access site is used for IV administration when possible. C. Verify the correct fluid type and rate as per the physician's order. D. Monitor for signs of infiltration or extravasation at the IV site.

Correct Answer is C

Explanation

Choice A reason: Checking the patient's blood pressure before and after IV administration is important, but it is not the most critical action to ensure safety during the procedure.

Choice B reason: Ensuring the dialysis access site is used for IV administration when possible is not standard practice. The dialysis access site is typically reserved for dialysis treatments to prevent complications.

Choice C reason: Verifying the correct fluid type and rate as per the physician's order is the most important action. Ensuring the right fluid type and rate prevents potential complications such as fluid overload, electrolyte imbalances, and adverse reactions.

Choice D reason: Monitoring for signs of infiltration or extravasation at the IV site is important, but verifying the correct fluid type and rate takes precedence to prevent any errors in the initial setup.

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The nurse is caring for a patient with a history of chronic kidney disease who was admitted with hypervolemia. As part of discharge planning, which instruction will the nurse provide to help the patient accurately monitor their fluid balance?

Nursing Test Bank

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