Which intervention should the nurse implement to manage a client’s fluid and electrolyte balance?

Monitor daily urine output volume

Use salt tablets after strenuous exercise

Review food labels for sodium content

Drink plenty of water whenever thirsty

Answer and Explanation

The Correct Answer is A

Choice A reason: Monitoring daily urine output assesses kidney function and fluid balance, as urine volume reflects hydration and electrolyte homeostasis. Inadequate output signals dehydration or renal issues, allowing timely intervention to maintain fluid and electrolyte balance, making it the most effective nursing action.

Choice B reason: Salt tablets after exercise replace sodium lost in sweat but are not a universal intervention for fluid and electrolyte balance. They risk hypernatremia if overused. Monitoring urine output is more comprehensive, as it directly evaluates fluid status across various clinical scenarios.

Choice C reason: Reviewing food labels for sodium content helps manage dietary intake but is indirect and patient-dependent. Urine output monitoring provides objective data on fluid and electrolyte status, enabling timely adjustments in therapy, making it a more immediate and reliable intervention.

Choice D reason: Drinking water when thirsty supports hydration but relies on subjective thirst, which may be impaired in certain conditions. Monitoring urine output objectively assesses fluid balance, detecting imbalances early, making it a more proactive and precise intervention than thirst-driven hydration.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Age over 40 increases cholelithiasis risk due to reduced gallbladder motility and increased bile cholesterol saturation, promoting gallstone formation. Aging alters bile composition, with higher lithogenic potential, making older adults more susceptible to cholesterol gallstones, a primary type in Western populations.

Choice B reason: Daily walking of 2 to 3 miles reduces cholelithiasis risk by promoting physical activity, which enhances gallbladder motility and reduces bile stasis. Exercise lowers cholesterol levels in bile, decreasing stone formation, making this a protective factor rather than a risk.

Choice C reason: A low-fat diet decreases cholelithiasis risk by reducing dietary cholesterol intake, which lowers bile cholesterol saturation. This promotes healthier bile composition, reducing the likelihood of cholesterol gallstone formation, making it a protective dietary habit rather than a risk factor.

Choice D reason: Male gender is associated with a lower risk of cholelithiasis compared to females, who have higher estrogen levels that increase bile cholesterol. Men have less lithogenic bile, making gender a protective factor, not a significant risk, unlike age-related changes.

A. Replace the gauze with a transparent dressing B. Apply a hydrocolloid gel dressing C. Leave the dressing off until consulting with the healthcare provider D. Increase the frequency of the dressing changes

Correct Answer is B

Explanation

Choice A reason: Transparent dressings are semi-permeable, suitable for superficial wounds with minimal exudate. Stage 3 pressure injuries, with deeper tissue damage and granulation, require moisture-retentive dressings to support healing. Transparent dressings may not provide the moist environment needed for optimal granulation tissue formation and epithelialization in deeper wounds.

Choice B reason: Hydrocolloid gel dressings maintain a moist wound environment, ideal for stage 3 pressure injuries with granulation tissue. They promote autolytic debridement, support epithelialization, and protect the wound. This is the best choice, as gauze may adhere to granulation tissue, causing trauma during removal, unlike hydrocolloids, which foster healing.

Choice C reason: Leaving the dressing off exposes the wound to infection and drying, which impairs granulation tissue and delays healing. Stage 3 pressure injuries require a moist, protected environment. Consulting the provider may be appropriate for complex cases, but immediate dressing application is standard to maintain optimal wound conditions.

Choice D reason: Increasing dressing change frequency may disrupt granulation tissue and delay healing, especially with gauze, which can adhere to the wound bed. Stage 3 pressure injuries benefit from stable, moist environments provided by advanced dressings like hydrocolloids, not frequent changes that risk trauma and infection.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which intervention should the nurse implement to manage a client’s fluid and electrolyte balance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is reviewing risk factors for cholelithiasis in a client’s history. Which factor most significantly increases the client’s risk for developing gallstones?

Correct Answer is A

Explanation

The nurse is performing a routine dressing change for a client with a stage 3 pressure injury that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse is caring for a client who fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is provided with a history of vomiting twice. Which intervention should the nurse implement first?

The nurse is caring for a client with a history of depression who is prescribed a selective serotonin reuptake inhibitor (SSRI). Which side effect should the nurse monitor for?

To assess the quality of an adult client’s pain, which approach should the nurse use?

A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?

The nurse is caring for a client with a history of gout. Which dietary recommendation should the nurse emphasize?

An older adult female client is hospitalized with a fractured femur. During a routine nursing assessment, she repeatedly asks the nurse to “speak up” so that she can hear the questions. Which action is best for the nurse to take?

A client is admitted to the emergency department with a suspected myocardial infarction. Which laboratory test should the nurse prioritize to confirm the diagnosis?

The nurse is caring for a client with a history of hypertension. Which lifestyle modification should the nurse emphasize?