A nurse is caring for several patients with fluid imbalances. A priority nursing intervention for a client with hypervolemia involves which of the following?
Monitoring respiratory status for signs and symptoms of pulmonary complications
Encouraging the client to consume sodium-free fluids
Weighing dressings with a large-bore catheter
Drawing a blood sample for typing and cross-matching
The Correct Answer is A
Choice A reason: Monitoring respiratory status for signs and symptoms of pulmonary complications is a priority nursing intervention for a client with hypervolemia. Hypervolemia is a condition where there is excess fluid in the blood vessels, which can cause fluid to leak into the lungs and impair gas exchange. The nurse should assess the client for signs of pulmonary edema, such as dyspnea, crackles, cough, and pink-tinged sputum.
Choice B reason: Encouraging the client to consume sodium-free fluids is not a priority nursing intervention for a client with hypervolemia. Sodium-free fluids may still contribute to fluid overload, especially if the client has impaired renal function or heart failure. The nurse should limit the client's fluid intake and administer diuretics as prescribed to reduce the fluid volume.
Choice C reason: Weighing dressings with a large-bore catheter is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client with hemorrhage, who may lose blood through a large-bore catheter or dressing. The nurse should monitor the client's blood pressure, pulse, and hemoglobin levels for signs of blood loss.
Choice D reason: Drawing a blood sample for typing and cross-matching is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client who needs a blood transfusion, which may be indicated for a client with anemia, trauma, or surgery. The nurse should check the client's blood type and compatibility before administering any blood products.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Including foods high in starch and proteins is not a specific dietary instruction for a client who has biliary colic from chronic cholecystitis. Starch and protein intake may vary depending on the client's overall nutritional needs and preferences.
Choice B reason: Including foods high in fiber is a general dietary recommendation for most people, but it is not directly related to biliary colic or cholecystitis. Fiber helps with bowel regularity and may lower the risk of some chronic diseases, but it does not affect the production or flow of bile.
Choice C reason: Avoiding foods high in sodium is a dietary instruction for clients who have hypertension, heart failure, or kidney disease, but it is not relevant for biliary colic or cholecystitis. Sodium intake does not influence the formation or dissolution of gallstones, which are the main cause of biliary colic.
Choice D reason: Avoiding foods high in fat is a dietary instruction for clients who have biliary colic from chronic cholecystitis. Fat intake stimulates the contraction of the gallbladder, which can cause pain and inflammation if there are gallstones blocking the bile ducts. Reducing fat intake can help prevent or reduce the frequency and severity of biliary colic episodes.
Correct Answer is D
Explanation
Choice A reason: This statement does not suggest that further health education is necessary. The client is expressing a realistic concern about the cost of the medication, which may be expensive or not covered by insurance. The nurse should acknowledge the client's financial situation and provide information about possible assistance programs or alternative options.
Choice B reason: This statement does not suggest that further health education is necessary. The client is expressing a reasonable anxiety about the medication, which may have side effects or interactions that require monitoring. The nurse should reassure the client and explain the purpose and frequency of the blood tests, as well as the potential benefits and risks of the medication.
Choice C reason: This statement does not suggest that further health education is necessary. The client is expressing a sense of wonder or skepticism about the medication, which may be uncommon or novel for the treatment of obesity. The nurse should educate the client about how the medication works and what to expect from the treatment, as well as the evidence and research behind it.
Choice D reason: This statement suggests that further health education is necessary. The client is expressing a false or unrealistic expectation about the medication, which is not a magic pill or a substitute for lifestyle changes. The nurse should correct the client and emphasize the importance of following a healthy diet and exercise regimen, as well as the goals and limitations of the medication.
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