A nurse is caring for a client who has fluid overload due to renal failure. Which of the following interventions should the nurse include in the plan of care?

Choice A reason: Feeling thirsty all the time is a sign of dehydration, not fluid loss. Dehydration occurs when the body does not have enough water and other fluids to carry out its normal functions. Dehydration can be caused by excessive sweating, vomiting, diarrhea, fever, or decreased water intake.

Choice B reason:

Gaining 2 pounds since yesterday is a sign of fluid retention, not fluid loss. Fluid retention occurs when the body holds on to extra water and salt in the tissues or blood vessels. Fluid retention can be caused by heart failure, kidney disease, liver disease, hormonal changes, or certain medications.

Choice C reason:

Having trouble breathing when lying down is a sign of orthopnea, not fluid loss. Orthopnea is a condition where a person feels short of breath when lying flat. Orthopnea can be caused by heart failure, lung disease, obesity, or sleep apnea.

Choice D reason:

Feeling dizzy when standing up is a sign of orthostatic hypotension, which is a possible sign of fluid loss. Orthostatic hypotension is a condition where the blood pressure drops when changing position from lying or sitting to standing. This can cause dizziness, lightheadedness, or fainting. Orthostatic hypotension can be caused by hypovolemia, which is a decrease in the volume of blood in the body due to fluid loss. Fluid loss can occur from bleeding, vomiting, diarrhea, sweating, or burns.

Choice A reason:

Administering IV fluids as prescribed is not an appropriate intervention for a client who has fluid overload due to renal failure. IV fluids will increase the fluid volume and worsen the condition. The nurse should monitor the client's fluid intake and output, and report any signs of fluid overload to the provider.

Choice B reason:

Restricting sodium intake is an appropriate intervention for a client who has fluid overload due to renal failure. Sodium causes water retention and increases the fluid volume in the body. The nurse should limit the client's sodium intake to less than 2 g per day, and avoid foods that are high in sodium, such as canned soups, processed meats, cheese, and salted snacks.

Choice C reason:

Elevating the head of the bed is an appropriate intervention for a client who has fluid overload due to renal failure. Elevating the head of the bed helps to reduce the pressure on the lungs and improve the client's breathing. The nurse should also monitor the client's respiratory status, and administer oxygen therapy as prescribed.

Choice D reason:

Encouraging ambulation is not an appropriate intervention for a client who has fluid overload due to renal failure. Ambulation may increase the workload on the heart and lungs, and exacerbate the symptoms of fluid overload. The nurse should assist the client with activities of daily living, and provide rest periods between activities.