Which is the most reliable method for monitoring fluid balance?

Correct Answer: A

Rationale: Monitoring daily intake and output is the most reliable method for assessing fluid balance in a patient. By accurately measuring the amount of fluids taken in through foods, drinks, and IV fluids, as well as the amount of fluids eliminated through urine, stool, vomit, and other means, healthcare providers can closely track the body's fluid balance. Discrepancies between intake and output can indicate potential issues such as dehydration or fluid overload. This method provides quantitative data that can guide appropriate interventions and treatment adjustments to maintain the patient's fluid balance within normal limits. While vital signs, daily weight, and skin turgor are also important indicators of fluid status, they may not always provide as specific or accurate information as the direct measurement of intake and output.

Correct Answer: C

Rationale: Radiation therapy for lung cancer is typically used with the goal of increasing comfort for the patient by reducing symptoms such as pain, shortness of breath, and coughing. While it may help to shrink tumors and slow the progression of the disease, it is usually not considered a curative treatment for advanced lung cancer. It is important for the patient to have realistic expectations and understand that the goal of radiation therapy is primarily to improve their quality of life and manage symptoms.

Correct Answer: C

Rationale: Bronchiectasis is a condition characterized by the abnormal widening and thickening of the bronchial tubes, leading to a build-up of mucus. One of the common assessment findings in clients with bronchiectasis is the expectoration of small amounts of sputum. This is due to the increased mucus production and impaired clearance from the airways. The sputum may be foul-smelling and may contain pus or blood due to chronic infection and inflammation in the bronchial tubes.

Correct Answer: B

Rationale: Chorea is the result of central nervous system manifestations. Chorea is a movement disorder characterized by involuntary, brief, random, and irregular muscle movements that are often seen in neurological conditions such as Huntington's disease. The central nervous system is responsible for controlling and coordinating movements, so any dysfunction in the central nervous system can lead to movement disorders like chorea. Therefore, chorea is directly related to central nervous system manifestations, unlike congestive heart failure, valve damage, or pericarditis which are primarily related to cardiovascular issues.

Correct Answer: D

Rationale: In the scenario of a patient developing an anaphylactic reaction to penicillin via IV piggyback, the nurse's first action should be to discontinue the administration of the antibiotic to prevent further exposure and potential worsening of the reaction. Turning off the antibiotic is critical as it stops the source of the allergic reaction. This step takes precedence over any other actions including calling the doctor, maintaining the antibiotic, or calling for help, as stopping the infusion is the most immediate and important action to take in managing an anaphylactic reaction. Once the antibiotic has been turned off, the nurse can then proceed with providing appropriate emergency treatments and notifying the healthcare team for further management.