NORCET 5 Prelims - Sept 2023 (Shift-1)
Medical & Surgical Nursing
Medium
A patient who is receiving vasopressin. Which of the following is a best assessment for fluid status?
Appeared in: NORCET 5 Prelims - Sept 2023 (Shift-1)
Explanation
- Vasopressin is an antidiuretic hormone (ADH) that promotes water reabsorption in the kidneys, putting the patient at risk for fluid volume excess (hypervolemia) and water intoxication.
- Daily weight is the most sensitive and reliable indicator of a patient's fluid status.
- A weight gain or loss of 1 kg (2.2 lbs) overnight is equivalent to 1 liter of fluid retained or lost.
- Monitoring daily weight allows for the early detection of fluid imbalances, which is critical for patients on vasopressin therapy.
Why Other Options Were Wrong
- Option B: Monitoring for constipation assesses gastrointestinal motility. While severe dehydration can cause constipation, it is not a direct or sensitive measure of the fluid retention that is the primary concern with vasopressin.
- Option C: Testing for glycosuria (sugar in the urine) is an assessment for hyperglycemia, typically related to diabetes mellitus. It has no role in monitoring fluid status related to vasopressin administration.
- Option D: This is a nursing intervention (an action), not an assessment (a data collection method). The question asks for the best assessment.
Related Visual
Clinical Relevance
- Nursing practice connection: Use the key finding related to Fluid status assessment during vasopressin therapy to guide bedside assessment, documentation, and the next nursing action.
- Accurate fluid status assessment is a critical nursing responsibility to prevent complications like fluid overload, pulmonary edema, and severe hyponatremia in patients receiving vasopressin.
- Nurses must ensure that daily weights are measured consistently: at the same time each day (preferably in the morning after voiding), using the same scale, and with the patient wearing similar clothing.
- What if? If a patient on vasopressin gains 2 kg in 24 hours and reports a headache, the nurse's priority is to assess for other signs of fluid overload and hyponatremia (e.g., check lung sounds for crackles, assess level of consciousness) and immediately notify the healthcare provider, as these are signs of water intoxication.
How to Approach the Question
- First, identify the key terms in the question: 'vasopressin', 'best assessment', and 'fluid status'.
- Recall the mechanism of action of vasopressin: it is an antidiuretic hormone (ADH) that causes the body to retain water.
- Analyze the core task: the question asks for an 'assessment', which means a method of gathering data, not performing an action (intervention).
- Evaluate each option. Option D, 'Restrict fluid intake', is an intervention, so it can be eliminated immediately.
- Compare the remaining assessment options (A, B, C) based on their relevance and sensitivity for monitoring fluid status. Daily weight is the most direct and accurate measure of total body fluid changes, making it superior to assessing for constipation or glycosuria.
Concept Tested & Keywords
- Concept Tested: Fluid status assessment during vasopressin therapy
- Stem keywords: vasopressin, fluid status, assessment
- Lead-in keywords: best
- Clinical cues: Patient receiving vasopressin, which is an antidiuretic hormone (ADH) that causes water retention.
Question ID
QcCPEFde3tlUGXsq5H6biK
Reference Book
E6 Nursing Fundamentals Potter Perry 12e Part 5 p. 61-63
E6 Nursing Brunner Adult Health 3SA Vol 1 Part 1 p. 143-145
Practise the full NORCET 5 Prelims - Sept 2023 (Shift-1)
Attempt every question from this paper in a timed mock, then review the full solution for each one.
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