A nurse is caring for a client who has acute renal failure. Which of the following
assessments provides the most accurate measure of client's fluid
... [Show More] status?
- daily weight--> daily weight provides important information about client's fluid
status. A gain or loss of 1 kg (2.2lb) indicates a gain or loss of 1 L of fluid;
therefore, weighing the client daily will provide the nurse with the most accurate
fluid status measurement
- not intake and output; it does reflect client's fluid status, but not the most accurate
method to measure fluid changes
A nurse is teaching a client who has lower extremity weakness how to use a 4-
point crutch gait. Which of the following instructions should the nurse include in
the teaching?
- "bear weight on both of your legs" –
- the client has 3 points on the ground at all times. Therefore, he must be able to
bear weight on both legs
A nurse is preparing to administer a cleansing enema to a client. Which of the
following actions should the nurse plan to make?
- position the client on his left side
A nurse is assessing a client who has heart failure. Client has gained weight since
her last visit and her ankles are edematous. Which of the following findings by the
nurse is another clinical manifestation of fluid volume excess?
- bounding pulse
A nurse is planning care for a client who has a single-lumen NG tube for gastric
decompression. Which of the following actions should the nurse include in the plan
of care? –
- provide oral hygiene frequently
- measure drainage from the NG tube every shift
- secure the NG tube to client's gown
- apply a water-soluble lubricant to the nares to prevent/relieve dry skin
A nurse is reviewing the lab values for a client who has a positive Chvostek's sign.
Which of the following lab findings should the nurse expect?
- decreased calcium-- calcium is necessary for nerve conduction and muscle
contractions. When client's total calcium level is below 8.4 mg/dl, tetany and
muscle spasms may occur. The nurse should tap the facial nerve in front of client'sear. If facial twitching follows this stimulus, it's a positive Chvostek's sign and an
indication of hypocalcemia [Show Less]