A client with hypovolemia is at risk for orthostatic hypotension. Which of the following interventions should the nurse implement in this client?
Encourage the client to change positions
Encourage the client to exercise vigorously
Encourage the client to stand for extended periods
Encourage the client to limit fluid intake
The Correct Answer is A
A. Encouraging the client to change positions slowly, such as moving from lying to sitting and then to standing, helps to minimize the risk of orthostatic hypotension. This gradual change allows the body to adjust to positional changes without causing a sudden drop in blood pressure.
B. Encouraging vigorous exercise is not recommended for a client with hypovolemia as it could exacerbate the condition, potentially causing dizziness, fainting, or further lowering blood pressure.
C. Encouraging the client to stand for extended periods is not appropriate for a client at risk for orthostatic hypotension, as standing for prolonged periods can cause blood to pool in the lower extremities, increasing the risk of fainting or dizziness.
D. Encouraging the client to limit fluid intake is inappropriate for a client with hypovolemia. Adequate fluid intake is crucial to help restore blood volume and prevent hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Upper UTI refers to infections that affect the kidneys (pyelonephritis) and ureters. These infections are typically more serious and can lead to kidney damage if not treated promptly.
B. Lower UTI refers to infections that affect the bladder (cystitis) or urethra (urethritis), which are generally less severe than upper UTIs.
C. Urosepsis is a severe, systemic infection that results from a UTI that has spread to the bloodstream. It can occur with either upper or lower UTIs.
D. Uncomplicated UTI refers to a straightforward infection of the urinary tract, typically involving the bladder, in an otherwise healthy individual. It is not specifically related to the kidneys or ureters.
Correct Answer is B
Explanation
A. Administering oxygen is important, but the priority is reversing the opioid-induced respiratory depression with naloxone. Oxygen alone will not address the underlying cause of the decreased level of consciousness.
B. Administering naloxone (Narcan) is the priority intervention because it is an opioid antagonist that will reverse the effects of morphine and other opioids, improving respiratory function and consciousness.
C. Opening the airway is important, but the primary issue here is opioid overdose, which requires naloxone administration for reversal of respiratory depression.
D. Placing the patient in the shock position is not indicated in this scenario. The focus should be on reversing opioid toxicity, not on positioning for shock.
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