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 B

Explanation

Choice A reason: Rechecking blood glucose immediately is not the appropriate immediate intervention when a patient shows signs of hypoglycaemia with a blood glucose level of 55 mg/dL. Immediate treatment is needed to raise the blood glucose level to prevent further complications.

Choice B reason: Providing 15 grams of fast-acting carbohydrates is the immediate intervention for a patient with hypoglycaemia. Fast-acting carbohydrates such as glucose tablets, juice, or regular soda can quickly raise blood glucose levels. This intervention addresses the immediate need to correct hypoglycaemia symptoms such as diaphoresis and palpitations.

Choice C reason: Administering 1 mg of glucagon intramuscularly is typically reserved for severe hypoglycaemia when the patient is unconscious or unable to ingest carbohydrates. In this scenario, the patient is conscious and able to consume fast-acting carbohydrates.

Choice D reason: Preparing an insulin subcutaneous injection is not appropriate for treating hypoglycaemia. Insulin lowers blood glucose levels and would worsen the patient's hypoglycaemic state.

A. Hypoventilation B. Panic attacks C. Pneumonia D. Congestive heart failure

Correct Answer is B

Explanation

Choice A reason: Hypoventilation is not a cause of respiratory alkalosis. Hypoventilation leads to respiratory acidosis due to the retention of carbon dioxide (CO2). Respiratory alkalosis occurs when there is excessive exhalation of CO2, leading to a higher pH (alkaline).

Choice B reason: Panic attacks can cause respiratory alkalosis due to hyperventilation. During a panic attack, a person may breathe rapidly and deeply, leading to excessive loss of CO2. This reduces the CO2 levels in the blood and increases the pH, resulting in respiratory alkalosis.

Choice C reason: Pneumonia is more likely to cause respiratory acidosis or metabolic acidosis rather than respiratory alkalosis. Pneumonia can impair gas exchange, leading to CO2 retention and decreased oxygen levels, which are not typical triggers for respiratory alkalosis.

Choice D reason: Congestive heart failure can lead to respiratory alkalosis, but it is more commonly associated with metabolic acidosis due to poor perfusion and anaerobic metabolism. Hyperventilation in heart failure patients can lead to respiratory alkalosis, but panic attacks are a more direct and common cause.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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