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.
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Related Questions
Correct Answer is D
Explanation
A. Administering furosemide (a diuretic) would worsen dehydration and is contraindicated in this scenario. The goal is to rehydrate the client, not to promote fluid loss.
B. Educating the client that oral fluids are not necessary is incorrect. Oral fluids are important for rehydration, and the client should be encouraged to drink fluids unless contraindicated.
C. Monitoring the client's weight once a week is not sufficient for assessing dehydration status. More frequent monitoring is needed to assess the effectiveness of treatment.
D. Monitoring the client's IV site and infusion is essential to ensure that the IV is patent, the fluid is being infused properly, and there are no complications such as infiltration or infection. This is a key aspect of nursing care for clients receiving IV fluids.
Correct Answer is D
Explanation
A. While impaired perineal skin integrity is a concern due to frequent diarrhea, it is not the priority because it does not pose an immediate threat to the client’s overall health or survival.
B. Protein-calorie malnutrition is a long-term risk associated with Crohn’s disease but is less critical during an acute exacerbation compared to immediate risks like fluid and electrolyte imbalance.
C. Although pain related to abdominal cramping is a significant concern, addressing pain does not take precedence over life-threatening risks such as dehydration or electrolyte disturbances.
D. Fluid and electrolyte imbalance is the priority because severe diarrhea can rapidly lead to dehydration, hypovolemia, and electrolyte imbalances, which can cause life-threatening complications such as cardiac arrhythmias or shock.
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