Physiological Adaptation Practice Question

Question

The nurse is caring for a postoperative client and is focused on fluid balance scenario 1. Which nursing action is most appropriate?

Answer choices

1. A. Delay assessment until the next scheduled round if the client is not calling for help.
2. B. Monitor intake, output, daily weight, edema, and lung sounds.
3. C. Delegate the clinical assessment and nursing judgment to assistive personnel.
4. D. Document the concern without notifying the appropriate provider or care team member when escalation is needed.

Correct Answer

B. Monitor intake, output, daily weight, edema, and lung sounds.

Explanation

The priority action for fluid balance is to monitor intake, output, daily weight, edema, and lung sounds. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

• Difficulty: medium
• Domain: Physiological Adaptation
• Objective: fluid balance

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