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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because successful communication requires the efforts of all people involved in a conversation. Even when the person with hearing loss utilizes hearing aids and active listening strategies, it is crucial that others involved in the communication process consistently use good communication strategies. One of these strategies is to face the hearing-impaired person directly, on the same level and in good light whenever possible. Position yourself so that the light is shining on the speaker's face, not in the eyes of the listener ¹.
Correct Answer is A
Explanation
Total parenteral nutrition (TPN) is a form of nutrition that is administered intravenously when a client is unable to eat or absorb nutrients orally or enterally. TPN solutions contain a high concentration of glucose, which provides the body with energy. Therefore, the nurse must closely monitor the client's glucose levels, as TPN can cause hyperglycemia (high blood sugar levels).
Frequent monitoring of blood glucose levels is necessary to ensure that the client's blood sugar stays within an acceptable range. Hyperglycemia can lead to a variety of complications, including dehydration, electrolyte imbalances, and damage to organs such as the kidneys and eyes. If the client's blood glucose levels are consistently high, adjustments to the TPN solution may be necessary, or insulin may need to be administered to help regulate blood sugar levels.
Therefore, glucose is the laboratory result that the nurse must closely monitor when a client is receiving TPN via a central venous access device (CVAD).
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