A nurse is assisting in the plan of care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take?
Encourage the client to use guided imagery to relax.
Elevate the head of the client's bed.
Increase the client's fluid intake.
Instruct the client to perform the Valsalva maneuver.
Instruct the client to perform the Valsalva maneuver.
The Correct Answer is C
Choice A reason : Guided imagery is a relaxation technique that can help reduce stress and anxiety, but it does not directly address the physiological issues of dehydration and hypotension. While it may be beneficial as a complementary therapy, it is not the primary intervention for a patient suffering from these conditions.
Choice B reason : Elevating the head of the bed is generally recommended for patients who have difficulty breathing or to prevent aspiration, but it is not the standard care for hypotension. In fact, for a hypotensive patient, elevating the legs might be more beneficial to promote venous return to the heart⁹[^20^].
Choice C reason : Increasing fluid intake is the most direct and effective way to treat dehydration. When a patient is hypotensive, it often indicates a low blood volume, which can be improved by increasing fluid intake. This can be done orally if the patient is conscious and able to drink, or intravenously if they are not. The normal range for blood pressure is 90/60 mmHg to 120/80 mmHg, and maintaining adequate hydration helps to ensure blood pressure stays within this range⁸.
Choice D reason : The Valsalva maneuver is a technique used to potentially correct certain types of abnormal heart rhythms, particularly supraventricular tachycardia, and not for treating hypotension or dehydration. It involves increasing intrathoracic pressure by exhaling forcefully with a closed airway, which can have various effects on the cardiovascular system. However, it is not an appropriate intervention for a dehydrated, hypotensive patient⁹[^10^].
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason : Epinephrine is an adrenergic agonist primarily used in the management of cardiac arrest, anaphylaxis, and severe asthma attacks. It is not used to reverse the effects of warfarin overdose. Warfarin acts as an anticoagulant by inhibiting vitamin K-dependent clotting factors, and epinephrine has no role in this mechanism.
Choice B reason : Vitamin K is the antidote for warfarin toxicity. Warfarin works by inhibiting the vitamin K-dependent clotting factors II, VII, IX, and X. In the event of an overdose, vitamin K is administered to reverse the anticoagulant effects of warfarin and restore the clotting factor levels to normal. The administration can be oral or intravenous, depending on the severity of the overdose and the urgency of the situation.
Choice C reason : Atropine is an anticholinergic drug used to treat bradycardia (slow heart rate) and as an antidote for organophosphate poisoning. It does not have a role in reversing warfarin overdose as it does not affect the clotting cascade or vitamin K metabolism.
Choice D reason : Protamine is used to reverse the effects of heparin, another anticoagulant, but not warfarin. Protamine sulfate binds to heparin, forming a stable complex and neutralizing its anticoagulant effects. Since warfarin's mechanism of action is different from heparin's, protamine is not effective in reversing warfarin toxicity.
Correct Answer is ["50"]
Explanation
Step 1 is to calculate the total drops (gtt) the nurse needs to administer. This is done by multiplying the volume of the solution (400 mL) by the drop factor (60 gtt/mL). So, 400 mL × 60 gtt/mL = 24000 gtt.
Step 2 is to calculate the total time in minutes over which the IV should be administered. Since there are 60 minutes in an hour, 8 hours is equivalent to 8 hours × 60 min/hour = 480 minutes.
Step 3 is to calculate the rate at which the IV should be administered. This is done by dividing the total drops by the total time. So, 24000 gtt ÷ 480 min = 50 gtt/min.
The nurse should set the manual IV infusion to deliver approximately 50 gtt/min.
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