NU 211: Exam 3 questions with correct answers

You are the nurse assessing a patient. What are some signs of excess fluid volume (hypervolemia) - correct answer edema/ascites, crackles in the lungs, pale, cool skin, elevated blood pressure, bounding pulse What med will help with fluid volume excess? - correct answer diuretic (lasix) med will help pt urinate out excess fluid-- may cause potassium loss A patient who is obese is admitted with a diagnosis of congestive heart failure. The nursing history reveals the patient has diabetes, smokes 2 packs of cigarettes daily, and is noncompliant with diet, exercise, and medications. The student nurse assigned to the patient states, "Let's focus on making them compliant, which will solve all the problems. Otherwise, we can't help them." What is the most appropriate response? - correct answer Only compliance will not fix the issue of taking meds and lifestyle changes. Start with some baby steps. Start with cutting down to one pack a day. Nurse must understand that the client must change themselves and take control over their health. How can we measure fluid status on patient? - correct answer Taking a daily weight (usually in the morning) at the same time every day What are some signs a patient with deficit fluid volume (hypovolemia) present? - correct answer dehydration, dry skin, dry mucous membranes, non-elastic skin turgor, decreased uring output and hypotension, increased heart rate, rise in temperature, weight loss What are some fluid volume nursing diagnoses? - correct answer -deficient fluid volume -excess fluid volume -risk for deficient fluid volume -risk for imbalanced fluid volume