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.

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Correct Answer is B

Explanation

Choice A reason: Serum creatinine assesses kidney function, not cardiac injury. While relevant for overall health, it does not confirm myocardial infarction. Troponin is specific to cardiac muscle damage, making it the priority test to diagnose acute coronary events in the emergency setting.

Choice B reason: Troponin levels are the gold standard for diagnosing myocardial infarction, as they rise within hours of cardiac muscle injury due to ischemia. High specificity for heart tissue makes troponin critical for confirming acute coronary syndrome, guiding urgent treatment in the emergency department.

Choice C reason: Complete blood count evaluates anemia or infection but is nonspecific for myocardial infarction. While useful for overall assessment, it does not detect cardiac injury. Troponin directly indicates heart muscle damage, making it the priority test for confirming the diagnosis.

Choice D reason: Blood glucose may be elevated in stress or diabetes but is not diagnostic for myocardial infarction. Cardiac-specific markers like troponin are essential for confirming heart injury, as glucose levels lack specificity for acute coronary events, making them secondary.

A. Remove ties to secure a disposable, soft foam collar with hook and loop fastener B. Secure tracheostomy ties by making knots close to the tube C. Leave the old ties in place until the new ones are secure D. Place knots of the ties lateral to prevent irritation and pressure

Correct Answer is C

Explanation

Choice A reason: Using a soft foam collar may reduce skin irritation but risks dislodging the tracheostomy tube if not secured properly. Leaving old ties in place until new ones are secure ensures tube stability, preventing accidental decannulation, which is critical in early tracheostomy care.

Choice B reason: Knots close to the tracheostomy tube increase pressure on the skin, risking irritation or necrosis. This is incorrect, as ties should allow slight movement. Maintaining old ties until new ones are secure prevents tube displacement, prioritizing airway safety during the procedure.

Choice C reason: Leaving old ties in place until new ones are secure prevents tracheostomy tube dislodgement, a life-threatening risk. This ensures continuous airway patency during tie changes, especially in fresh tracheostomies, making it the safest and most critical action to maintain tube stability.

Choice D reason: Placing knots laterally reduces irritation but does not address the risk of tube dislodgement during tie changes. Keeping old ties in place until new ones are secure is the priority, as it ensures the tube remains stable, preventing airway compromise.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is C

Explanation

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