Which is the most reliable method for monitoring improvement when restoring fluid balance?

Vital signs

skin turgor

Daily input and output

Daily weights

Answer and Explanation

The Correct Answer is D

A. Vital signs: Vital signs can reflect changes in fluid status, but they are not always sensitive to small shifts in fluid balance and can be affected by many other factors like medications.

B. Skin turgor: Skin turgor can be useful for assessing dehydration but is not a reliable indicator for tracking fluid balance over time, especially in older adults where skin elasticity naturally declines.

C. Daily input and output: Monitoring intake and output is useful, but it is not the most reliable for evaluating overall fluid balance, especially in cases of insensible loss or shifts in third spaces.

D. Daily weights: Weighing the patient daily is the most reliable method for monitoring fluid balance because it directly reflects changes in fluid retention or loss, particularly in acute or chronic conditions like heart failure or dehydration.

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Correct Answer is B

Explanation

A. Peripheral pulses +1: Weak peripheral pulses indicate continued hypovolemia or dehydration. Effectiveness would be reflected in stronger pulses.

B. Urine output 200 mL/4 hr: Adequate urine output (≥30 mL/hr) indicates improved kidney perfusion and hydration status, suggesting effective treatment.

C. Urine specific gravity 1.04: This value is elevated, indicating continued dehydration; effective hydration would reduce this value to the normal range of 1.005-1.030.

D. Heart rate 104/min: Tachycardia is a compensatory response to dehydration. Improvement would manifest as a normalized heart rate (60-100 bpm).

A. Upright B. Side-lying C. Supine D. Prone

Correct Answer is A

Explanation

A. Upright: Sitting upright promotes optimal lung expansion by reducing pressure on the diaphragm and improving ventilation.

B. Side-lying: This may be used for comfort but does not maximize lung expansion.

C. Supine: Lying flat can compromise lung expansion, particularly in respiratory distress.

D. Prone: While prone positioning is used in specific cases of severe respiratory failure (e.g., ARDS), it is not standard for general pneumonia in children.

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Which is the most reliable method for monitoring improvement when restoring fluid balance?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement. Which of the following findings should the nurse identify as effectiveness of the treatment?

Correct Answer is B

Explanation

A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has a calcium level of 12 mg/dL (9-10.5 mg/dL). Which of the following manifestations should the nurse expect?

The nurse is caring for a group of patients. Which patient is at highest risk for hypovolemia?

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A nurse is assisting in the care of a client in the emergency department. Exhibits Complete the following sentence by using the list of options. The nurse should first address the client's dropdown followed by the client's dropdown .

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