A client with diabetes insipidus is extremely dehydrated and is unable to take oral fluids. Fluid therapy is prescribed. Which intervention would be most important for the client?
Monitoring the rate of IV infusions.
Weighing the client daily.
Measuring the urine output every 30 minutes.
Measuring the fluid intake.
The Correct Answer is A
Monitoring the rate of IV infusions. In clients with diabetes insipidus, fluid therapy is essential to restore hydration levels. It is important to monitor the rate of IV infusion to avoid rapid administration of fluids, which can lead to fluid overload and pulmonary edema. Therefore, monitoring the rate of IV infusions is the most important intervention for this client.
Choice B, weighing the client daily, is incorrect because it is not the most important intervention for this client. While daily weighing is important for monitoring fluid balance, monitoring the rate of IV infusion is more critical.
Choice C, measuring the urine output every 30 minutes, is incorrect because although it is important to monitor urine output in clients with diabetes insipidus, it is not the most important intervention. Monitoring the rate of IV infusion is more critical to prevent fluid overload.
Choice D, measuring the fluid intake, is incorrect because although it is important to monitor fluid intake in clients with diabetes insipidus, it is not the most important intervention. Monitoring the rate of IV infusion is more critical to prevent fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Enuresis. Enuresis is the involuntary discharge of urine after the age at which bladder control should have been established. It is a normal finding for children up to the age of 5 years. Hematuria, Anuria, and Dysuria are abnormal findings related to the urinary system and are not normal findings for a 3-year-old.
Choice A, Hematuria, is incorrect because it is an abnormal finding related to the urinary system.
Choice C, Anuria, is incorrect because it is an abnormal finding related to the urinary system.
Choice D, Dysuria, is incorrect because it is an abnormal finding related to the urinary system.
Correct Answer is D
Explanation
Radiographic confirmation. Radiographic confirmation is the most reliable method to verify the placement of nasogastric tubes, and it is considered the gold standard. The nurse should use it to confirm placement initially and periodically to ensure that the tube is in the stomach and not in the lungs or esophagus.
Option A, placing the end of the tube in water and observing for bubbling, is incorrect because it is not a reliable method, and it can cause aspiration or infection.
Option B, using the auscultation technique, is incorrect because it can lead to misinterpretation of bowel sounds, and it is not reliable.
Option C, measuring pH of aspirates, is incorrect because it is not a reliable method, and it can be affected by several factors, including medications, stress, and nutritional status.
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