The nurse provides care for a client recovering from a motor vehicle crash. For which sign of ﬂuid volume overload does the nurse measure the client's intake and output? (Select all that apply)

Productive cough

Heart rate 112 beats/min

Blood pressure 96/52 mm Hg

Weight gain of 2 kg (4.4 lb)

Edema +2 of bilateral ankles and feet

Answer and Explanation

Correct Answer : A,D,E

These are all signs of ﬂuid volume overload. Measuring the client's intake and output can help the nurse monitor the client's ﬂuid balance and detect any imbalances. A productive cough may indicate ﬂuid accumulation in the lungs.

Weight gain and edema are also signs of ﬂuid retention.

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Correct Answer is A

Explanation

A rectal temperature should not be taken if the client has bradycardia because stimulation of the vagus nerve during the insertion of the rectal thermometer can result in a further decrease in heart rate. Hypertension, tachypnea, and pyrexia are not contraindications for taking a rectal temperature.

A. Client demonstrates correct glucose testing. B. Client says 'I can do the testing now'. C. Client explains the testing process to the nurse. D. Client observes the nurse test glucose 5 times.

Correct Answer is A

Explanation

This is because the outcome of the plan is for the client to learn self-glucose testing, which implies that the client can perform the testing correctly on their own. Option A shows that the client has successfully learned and can perform the skill independently, which is the ultimate goal of the plan.

Option B, "Client says 'I can do the testing now'," and option C, "Client explains the testing process to the nurse," may show that the client has some understanding of the testing process, but they do not demonstrate that the client can perform the skill independently.

Option D, "Client observes the nurse test glucose 5 times," is not an appropriate method for evaluating the client's ability to perform self-glucose testing. Observing the nurse perform the skill does not demonstrate that the client has learned the skill themselves.

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The nurse provides care for a client recovering from a motor vehicle crash. For which sign of ﬂuid volume overload does the nurse measure the client's intake and output? (Select all that apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse delegated vital signs for a group of patients to the unlicensed assistive personnel (UAP). Which client condition would prohibit having a rectal temperature taken by the UAP?

Correct Answer is A

Explanation

The nurse evaluates a client's plan of care. The client has an outcome of 'Client will learn self-glucose testing before discharge'. When evidence best allows the nurse to meet the outcome of the plan?

Correct Answer is A

Explanation

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