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

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: This is not a correct result that the nurse should anticipate. RBC stands for red blood cells, which carry oxygen and carbon dioxide in the blood. The normal range for RBC is 4-5.5 /mm^3^, so a value of 4.2 /mm^3^ is within the normal range and does not indicate any abnormality.

Choice B reason: This is a correct result that the nurse should anticipate. WBC stands for white blood cells, which fight infections and inflammation in the body. The normal range for WBC is 5-10 /mm^3^, so a value of 17 /mm^3^ is above the normal range and indicates leukocytosis, which is an increase in the number of white blood cells. Leukocytosis can be caused by acute appendicitis, as the body tries to fight the infection and inflammation in the appendix.

Choice C reason: This is not a correct result that the nurse should anticipate. Neutrophils are a type of white blood cell that are the first to respond to bacterial infections. The normal range for neutrophils is 3-5.8 /mm^3^, so a value of 3.2 /mm^3^ is within the normal range and does not indicate any abnormality.

Choice D reason: This is not a correct result that the nurse should anticipate. Lymphocytes are a type of white blood cell that are involved in the immune response and the production of antibodies. The normal range for lymphocytes is 1-4 /mm^3^, so a value of 3 /mm^3^ is within the normal range and does not indicate any abnormality.

A. An antipyretic medication B. A diuretic medication C. A blood culture D. A fluid bolus

Correct Answer is D

Explanation

Choice A reason: An antipyretic medication is not the best answer because it does not address the client's low urine output. An antipyretic medication is a drug that lowers the body temperature by reducing the production of heat or increasing the loss of heat. It may help the client feel more comfortable, but it does not improve the kidney function or prevent dehydration.

Choice B reason: A diuretic medication is not the best answer because it may worsen the client's low urine output. A diuretic medication is a drug that increases the excretion of water and electrolytes by the kidneys. It may lower the blood pressure and reduce the fluid overload, but it may also cause dehydration, electrolyte imbalance, and kidney damage.

Choice C reason: A blood culture is not the best answer because it does not address the client's low urine output. A blood culture is a laboratory test that detects the presence of bacteria or other microorganisms in the blood. It may help identify the cause of the fever and guide the antibiotic therapy, but it does not improve the kidney function or prevent dehydration.

Choice D reason: A fluid bolus is the best answer because it may improve the client's low urine output. A fluid bolus is a rapid infusion of a large volume of fluid, usually isotonic saline or lactated Ringer's solution. It may increase the blood volume and pressure, improve the tissue perfusion, and stimulate the urine production. It may also help lower the fever by diluting the pyrogens and increasing the heat loss.

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A nurse is caring for several patients with fluid imbalances. A priority nursing intervention for a client with hypervolemia involves which of the following?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has acute appendicitis. Which of the following results should the nurse anticipate when reviewing this client's laboratory values?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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