The nurse is providing postoperative care for a male client who had a transurethral resection of the prostate (TURP) 4 hours ago and has continuous irrigation.
Which of the following actions should the nurse take to monitor the client for fluid overload?
Assess for hypotension.
Assess for distention above the pubis area.
Monitor the client's laboratory values for hypernatremia.
Maintain strict intake and output records.
The Correct Answer is D
Choice A rationale
Hypotension is not a typical sign of fluid overload. Fluid overload often presents with hypertension due to increased circulatory volume. Monitoring blood pressure is essential, but hypotension does not reliably indicate fluid overload. This option does not align with scientific understanding of fluid overload symptoms.
Choice B rationale
Distention above the pubis area suggests urinary retention or bladder distension rather than fluid overload. While important to assess, it does not directly indicate fluid overload. This symptom is more related to mechanical issues than systemic fluid imbalance and volume overload.
Choice C rationale
Hypernatremia is not a sign of fluid overload. Fluid overload typically results in dilutional hyponatremia, where excessive fluids lower sodium levels. Monitoring sodium levels is useful, but hypernatremia would suggest dehydration or other conditions, not excess fluid volume. This choice is inconsistent with scientific knowledge.
Choice D rationale
Maintaining strict intake and output records is a fundamental approach to monitoring fluid balance. Accurate measurements of fluid intake and output help detect fluid overload early. This method directly correlates with assessing excess fluid volume in clinical practice. It is a reliable, evidence-based intervention for monitoring fluid status. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Pregnant women may experience increased iron demands due to expanded blood volume and fetal requirements. However, prescribed prenatal vitamins typically contain sufficient iron to prevent deficiency. Compliance with supplementation reduces the risk for anemia, and pregnancy itself is not an independent factor without nutritional inadequacy. Other physiological conditions, such as menorrhagia or dietary restrictions, can significantly elevate risk factors for iron deficiency anemia.
Choice B rationale
Hypertension does not inherently increase the risk of iron deficiency anemia. Exercise three times a week is unlikely to create significant hematological challenges unless combined with conditions like poor dietary intake or chronic illness. Physical activity does not deplete iron stores unless excessive or accompanied by inappropriate nutrition. This client does not exhibit risk factors as critical as menorrhagia or dietary restrictions for anemia development.
Choice C rationale
Working long hours and consuming a high-carbohydrate diet might affect overall health, but these factors do not directly relate to iron absorption or blood loss. While poor nutritional habits can lead to deficiencies, high carbohydrate intake does not necessarily deplete iron reserves. A vegetarian or restrictive diet lacking iron-rich foods poses a greater risk for developing anemia than carbohydrate consumption alone.
Choice D rationale
Menorrhagia results in excessive blood loss during menstruation, which can deplete iron stores and lead to anemia. A strict vegetarian diet often lacks heme iron, which is more readily absorbed compared to non-heme iron from plant sources. Together, these factors create a dual risk of iron deficiency, emphasizing why this client is the most likely among the options to develop anemia. Nutritional counseling and supplementation are key preventive measures.
Correct Answer is ["12"]
Explanation
Step 1 is to convert 176 pounds to kilograms. (176 ÷ 2.2) = 80 kg.
Step 2 is to calculate the drug dose. (10 mcg × 80 kg) ÷ 1000 = 0.8 mg/minute.
Step 3 is to find the hourly dose. (0.8 mg × 60 minutes) = 48 mg/hour.
Step 4 is to calculate mL/hour. (48 mg ÷ (1000 mg ÷ 250 mL)) = 12 mL/hour. The final calculated answer is 12 mL/hour.
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