Which parameters are to be considered in Physical Assessment for Fluid and Electrolyte status? Select all that apply
Daily Weights
Moisture of oral cavity
Intake and Output
Edema
Listen
Skin turgor
Correct Answer : A,B,C,D,F
a) Daily Weights: Daily weights are an important measure for assessing fluid status, as they can indicate fluid retention or loss.
b) Moisture of oral cavity: The moisture of the oral cavity can be an indicator of dehydration, which affects fluid balance.
c) Intake and Output: Monitoring intake and output is essential for assessing the balance of fluids and electrolytes.
d) Edema: Edema, or fluid retention, is a key sign of altered fluid and electrolyte status.
e) Listen: While listening to lung sounds or heart sounds may provide indirect information about fluid balance, the word "listen" alone is too vague and not a specific parameter for fluid and electrolyte assessment.
f) Skin turgor: Skin turgor is a sign of hydration status. Decreased turgor may indicate dehydration.
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Related Questions
Correct Answer is D
Explanation
a) Dark black visible blood: Dark, black blood is typically a sign of blood that has been digested, often due to gastrointestinal bleeding, but this is not the definition of occult blood.
b) Bright red visible blood: Bright red blood is usually a sign of recent bleeding, often from hemorrhoids or anal fissures. Occult blood refers to blood that is not visible.
c) Blood that contains mucus: Blood with mucus is not the definition of occult blood. Occult blood refers to blood that is hidden and cannot be seen without further testing.
d) Blood that cannot be seen: Occult blood refers to hidden blood that is not visible to the naked eye but can be detected through specific tests, such as a fecal occult blood test (FOBT).
Correct Answer is A
Explanation
a) Compare the total intake and output of fluids for the 24 hours: To assess fluid balance and status, the nurse must compare the intake and output of fluids. This helps to determine whether the patient is retaining or losing fluids.
b) Compare the patient's intake with the normal range of adult fluid intake: While this is useful for understanding general fluid needs, it does not directly assess the patient's fluid status. The comparison should be between intake and output.
c) Ensure the information is included in the verbal end-of-shift report: While this is good practice, the focus should be on using the information to assess the patient's fluid balance.
d) Report the exact milliliter of intake to the physician's office nurse: The exact intake should be recorded in the patient's chart and used for clinical decision-making, but it does not need to be reported to a physician's office nurse unless specified.
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