The practical nurse (PN) is implementing a nursing care plan that requires daily weights. Which factor is most important for the PN to consider regarding daily weights?
The amount of fluid the client drank today.
When the client wants to be weighed.
When the client was last weighed.
The amount of food the client ate today
The Correct Answer is C
A. The amount of fluid the client drank today: Although fluid intake affects weight, daily weights are intended to reflect overall fluid and nutritional changes over time, not just today's intake. Monitoring intake is important but not the most critical factor in conducting daily weights consistently.
B. When the client wants to be weighed: While respecting the client's preferences is important for cooperation, clinical accuracy requires consistency in timing and conditions, not simply weighing at the client's preferred time.
C. When the client was last weighed: Knowing when the client was last weighed ensures consistency and accuracy for monitoring trends. Daily weights should be taken at the same time each day, ideally in the morning before eating and after voiding, to accurately track fluid balance and body mass changes.
D. The amount of food the client ate today: Food intake affects weight slightly, but the purpose of daily weights is to detect significant changes, such as fluid retention or loss. Weighing under consistent conditions matters more than focusing on the day's food intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Alteration in comfort: Restlessness, shallow breathing, and clenching teeth are strong indicators of discomfort or pain, especially in a client with aphasia who cannot verbalize needs. Assessing for pain or other sources of distress is the priority to address the client’s immediate comfort and prevent further deterioration.
B. Deficit in diversional activity: While limited activity can impact emotional health, signs like restlessness and physical tension suggest an immediate physical problem rather than boredom or inactivity. Comfort issues must be addressed first before considering diversional needs.
C. Elevated blood pressure: Stroke patients are at risk for hypertension, but restlessness and shallow respirations alone do not directly indicate elevated blood pressure. Blood pressure may rise secondary to pain or distress, but comfort assessment is still the initial focus.
D. Change in blood glucose level: Blood glucose fluctuations can cause changes in mental status or energy levels, but the client’s symptoms of clenching teeth and shallow breathing more strongly point toward discomfort or pain rather than hypoglycemia or hyperglycemia.
Correct Answer is C
Explanation
A. Discuss a low sodium diet: While teaching about a low sodium diet is important in managing fluid balance and hypertension, it is not the immediate intervention needed to address the acute symptoms and risks associated with the client's current condition.
B. Provide only distilled water: Distilled water is not necessary in managing acute kidney injury. Fluid intake management should be based on specific electrolyte and fluid needs, and the focus should be on controlling volume overload rather than the type of water provided.
C. Monitor for dependent pitting edema: Monitoring for pitting edema is critical because it provides immediate information about fluid overload, which is common with acute kidney injury. Assessing for edema provides information about the extent of fluid retention and helps evaluate the effectiveness of interventions aimed at managing fluid balance.
D. Use a cushion when sitting: Using a cushion may improve comfort but does not address the life-threatening complications of electrolyte imbalance, hypertension, and mental status changes associated with acute kidney injury. Priority should be on assessing and managing systemic symptoms.
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