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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. A client with heart failure and crackles in the lungs is more likely to have fluid volume excess rather than deficit.
B. A client with renal failure and pitting edema is typically at risk for fluid retention and overload, not deficit.
C. Being NPO for 4 hours is unlikely to cause significant fluid volume deficit, as this is a short period without oral intake.
D. A client with Crohn's disease experiencing diarrhea is losing significant fluids and electrolytes, placing them at high risk for fluid volume deficit. Diarrhea is a common cause of dehydration and requires close monitoring.

A. Jugular vein distention B. Crackles C. Dyspnea D. Hypotension E. Flat veins

Correct Answer is ["A","B","C"]

Explanation

A. Jugular vein distention is a common sign of fluid volume overload, as increased central venous pressure causes distention of the jugular veins.
B. Crackles heard during auscultation indicate pulmonary congestion or edema, a hallmark of fluid volume overload.
C. Dyspnea results from fluid accumulation in the lungs, impairing oxygen exchange and causing difficulty breathing.
D. Hypotension is not a sign of hypervolemia; instead, hypervolemia typically causes hypertension due to increased circulating volume.
E. Flat veins are indicative of hypovolemia, not hypervolemia. In hypervolemia, veins are typically distended due to the excess fluid volume.

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A client with hypovolemia is at risk for orthostatic hypotension. Which of the following interventions should the nurse implement in this client?

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Naxlex Comprehensive Predictor Exams

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