the nurse is caring for a client with fluid overload the most reliable indicator of fluid volume status is
Logo

Nursing Elites

HESI RN

RN HESI Exit Exam Capstone

1. The nurse is caring for a client with fluid overload. The most reliable indicator of fluid volume status is

Correct answer: C

Rationale: Daily weight is the most reliable indicator of fluid volume status as it reflects changes in body fluid balance accurately. Body weight alone can fluctuate due to various factors, including food intake and bowel movements, which may not accurately represent fluid status. Intake and output provide information on fluid balance over time but may not reflect immediate changes. Skin turgor is a physical assessment finding that indicates hydration status, not overall fluid volume status.

2. A client with heart failure has a prescription for digoxin. The nurse is aware that sufficient potassium should be included in the diet because hypokalemia in combination with this medication ____________.

Correct answer: A

Rationale: The correct answer is A: Can predispose to dysrhythmias. Hypokalemia combined with digoxin increases the risk of dysrhythmias due to the potentiation of digoxin's effects on cardiac conduction. Choice B, May lead to oliguria, is incorrect because hypokalemia is not typically associated with oliguria. Choice C, May cause irritability and anxiety, is incorrect as these symptoms are more commonly associated with hypocalcemia. Choice D, Sometimes alters consciousness, is incorrect as altered consciousness is not a typical effect of hypokalemia combined with digoxin.

3. The nurse is assessing a client with a new diagnosis of hyperthyroidism. Which assessment finding should the nurse expect?

Correct answer: B

Rationale: In hyperthyroidism, there is an increase in metabolism, leading to symptoms such as increased appetite, weight loss, and heat intolerance. Therefore, the nurse should expect an increased appetite in a client with hyperthyroidism. Choices A, C, and D are incorrect because decreased heart rate and cold intolerance are more commonly associated with hypothyroidism, while weight gain is not typically seen in hyperthyroidism.

4. A client with dysphagia is having difficulty swallowing medications. What is the nurse's best intervention?

Correct answer: C

Rationale: The best intervention for a client with dysphagia experiencing difficulty swallowing medications is to consult with the healthcare provider about switching to liquid medications. Liquid medications are often easier to swallow and can reduce the risk of choking and aspiration in clients with dysphagia. Crushing medications can alter their effectiveness, encouraging the client to drink water may not be sufficient, and offering soft foods is not directly related to improving medication swallowing.

5. A client with hyperthyroidism is admitted for total thyroidectomy. What is the nurse's priority post-operative intervention?

Correct answer: A

Rationale: The correct answer is to monitor the client's calcium levels for hypocalcemia. After a total thyroidectomy, there is a risk of accidental removal or damage to the parathyroid glands, leading to hypocalcemia. This complication can manifest within the first 24-48 hours post-op. Monitoring calcium levels is crucial to prevent serious complications such as tetany or seizures. While monitoring for respiratory distress is important, it is not the priority in this case. Administering oral calcium supplements should only be done based on the healthcare provider's prescription and after assessing the client's calcium levels. Elevating the head of the bed to 45 degrees is beneficial for respiratory function but is not the priority intervention for a client at risk for hypocalcemia post-thyroidectomy.

Similar Questions

An older client who had a subtotal parathyroidectomy is preparing for discharge. What finding requires immediate provider notification?
A client receiving lactulose for hepatic encephalopathy needs evaluation. Which assessment should the nurse prioritize?
To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?
A client who had a vasectomy is in the post-recovery unit at an outpatient clinic. Which of these points is most important to be reinforced by the nurse?
A client with osteoarthritis is prescribed acetaminophen. What is the most important teaching the nurse should provide?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses