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
A positive Romberg sign is indicated when a patient, asked to stand with feet together and arms at their side with eyes closed, sways significantly or loses balance. This suggests a deficit in proprioception, which is the sense of one's body position in space, as visual input cannot compensate for the impaired proprioceptive feedback to maintain equilibrium.
Choice B rationale
Homans' sign is a clinical indicator for deep vein thrombosis (DVT), assessed by dorsiflexing the foot and observing for calf pain. A negative Homans' sign means no pain is present, and it is unrelated to balance or coordination assessment.
Choice C rationale
Lack of coordination is a general term that could encompass various motor deficits, but "ataxia" is a more specific neurological term for impaired coordination. While swaying and moving feet apart demonstrate a lack of coordination, documenting it as a positive Romberg sign provides a more precise and diagnostically relevant finding in this specific context.
Choice D rationale
Ataxia refers to impaired coordination of voluntary movements, often appearing as clumsiness, inaccuracy, or instability. While the patient's actions exhibit ataxia, the specific maneuver performed (standing with eyes closed) and the resulting sway are characteristic of a positive Romberg sign, which points to a proprioceptive or vestibular deficit.
Correct Answer is ["0.5"]
Explanation
Step 1: The order is 10,000 units.
Step 2: The available concentration is 20,000 units per 1 mL.
Step 3: Calculate the volume to administer: 10,000 units ÷ (20,000 units ÷ 1 mL) = 0.5 mL. Answer: 0.5 mL.
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