When measuring a patient's weight, the nurse is aware of which of these guidelines?
The patient may leave on his or her jacket and shoes as long as these are documented next to the weight.
The type of scale does not matter, as long as the weights are similar from day to day.
Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
The patient is always weighed wearing only his or her undergarments.
The Correct Answer is C
Choice A rationale
While documenting additional clothing could mitigate some error, the presence of a jacket and shoes adds variable, unmeasured mass. Accurate weight measurement is crucial for medication dosing, fluid balance assessment, and nutritional status monitoring. Even seemingly minor additions can significantly skew results, impacting clinical decisions and potentially leading to suboptimal patient care.
Choice B rationale
The type of scale significantly impacts accuracy and precision. Different scales, such as beam scales, electronic scales, or bed scales, have varying calibration standards and sensitivities. Using a consistent, properly calibrated scale minimizes measurement variability and ensures reliable data, which is essential for tracking trends and making valid comparisons over time in a clinical setting.
Choice C rationale
Diurnal variations in body weight occur due to factors like fluid shifts, food and fluid intake, and bowel elimination. Weighing at the same time minimizes these transient fluctuations, providing a more consistent and comparable baseline for monitoring weight changes over time. This consistency is vital for accurate assessment of a patient's fluid status, nutritional progress, or response to therapeutic interventions.
Choice D rationale
While weighing in undergarments provides the most accurate baseline, it may not always be practical or appropriate due to patient comfort, privacy concerns, or clinical urgency. The goal is to standardize the weighing procedure as much as possible, including minimizing clothing and documenting any deviations to ensure consistency and interpretability of serial weight measurements.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The "prn" abbreviation stands for "pro re nata," which is Latin for "as needed.”. This indicates that the medication should be administered based on the patient's symptoms or specific needs, rather than on a fixed schedule. The nurse assesses the patient and administers the medication only when the patient exhibits the conditions for which the medication is prescribed, adhering to the minimum 6-hour interval for safety and therapeutic efficacy. This allows for individualized pain management.
Choice B rationale
This statement is incorrect because a "prn" order does not imply around-the-clock administration. Around-the-clock dosing is typically for scheduled medications where a consistent drug level is desired to manage chronic conditions or prevent symptoms, regardless of the patient's immediate need. Administering a prn medication routinely could lead to unnecessary drug exposure or adverse effects.
Choice C rationale
While waiting 6 hours between doses is crucial to prevent drug accumulation and toxicity, stating "I must wait 6 hours before administering this medication to you" is an incomplete explanation for a PRN order. The primary determinant for administration is the patient's need, not simply the passage of time. The 6-hour interval is a safety parameter to ensure adequate drug clearance and prevent exceeding therapeutic thresholds.
Choice D rationale
Administering a medication "over 6 hours" refers to the duration of infusion, not the frequency of administration. This statement is typically relevant for intravenous infusions where the drug is diluted and infused slowly over a specific period. A prn order for oral medication generally means an immediate dose is given when needed, and the interval between doses is 6 hours, not the infusion time.
Correct Answer is D
Explanation
Choice A rationale
Having the patient lie flat before administering medications through a tube increases the risk of aspiration, as gastric contents can reflux into the esophagus and potentially enter the airway. Proper patient positioning is crucial to promote safe medication delivery and prevent pulmonary complications.
Choice B rationale
Administering medications when gastric residual volume is 200 mL or more is generally not recommended. A high residual volume indicates delayed gastric emptying, increasing the risk of aspiration and potentially affecting medication absorption. Typically, residuals of 200-250 mL or more warrant holding the feeding and reassessing.
Choice C rationale
Mixing all medications together before administration is often inappropriate and can lead to several problems. Drug incompatibilities can occur, altering medication effectiveness, causing precipitation, or leading to tube occlusion. Each medication should generally be administered separately, flushed with water between doses.
Choice D rationale
Elevating the head of the patient's bed to at least 30 degrees before administering medications through a tube significantly reduces the risk of aspiration. This semi-Fowler's position utilizes gravity to keep gastric contents in the stomach, promoting safe passage of medications and minimizing reflux into the esophagus and lungs.
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