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: Calling the doctor for more antiemetic medication is not the best intervention for the nurse to facilitate. Antiemetics are drugs that prevent or reduce nausea and vomiting, but they may have side effects such as drowsiness, dry mouth, or constipation. The nurse should first try non-pharmacological measures to relieve the patient's nausea, such as giving small sips of water, providing a cool and quiet environment, or using aromatherapy.

Choice B reason: Giving the patient small sips of tepid water is the best intervention for the nurse to facilitate. Water can help hydrate the patient and dilute any stomach acid that may cause irritation. Tepid water is water that is slightly warm, which can be more soothing than cold or hot water. Small sips can prevent the patient from swallowing too much air, which can worsen nausea and vomiting.

Choice C reason: Helping the patient lay supine is not a good intervention for the nurse to facilitate. Supine means lying flat on the back, which can increase the risk of aspiration, or inhaling food or fluids into the lungs. Aspiration can cause pneumonia, a serious lung infection. The nurse should help the patient lay on their side, with their head elevated, to prevent aspiration and reduce pressure on the stomach.

Choice D reason: Showing the patient how to use the patient-controlled analgesia is not a relevant intervention for the nurse to facilitate. Patient-controlled analgesia is a system that allows the patient to self-administer pain medication through an IV pump. It has nothing to do with nausea and vomiting, and may even cause them as side effects. The nurse should monitor the patient's pain level and adjust the analgesia settings as needed, but not as a way to treat nausea.

A. Colonoscopy B. Magnetic resonance imaging (MRI) C. Abdominal ultrasound D. Computed tomography (CT) scan with contrast

Correct Answer is A

Explanation

Choice A reason: Colonoscopy is the most accurate diagnostic test for diverticulosis, which is the presence of pouches or sacs in the wall of the colon. It allows the direct visualization of the colon and the identification of any diverticula, polyps, or tumors. The nurse should prepare the client to undergo bowel preparation, sedation, and monitoring before and after the procedure.

Choice B reason: Magnetic resonance imaging (MRI) is not a diagnostic test for diverticulosis. It is a non-invasive imaging technique that uses a magnetic field and radio waves to create detailed images of the internal organs and tissues. It is more commonly used for brain, spine, joint, or soft tissue disorders.

Choice C reason: Abdominal ultrasound is not a diagnostic test for diverticulosis. It is a non-invasive imaging technique that uses sound waves to create images of the abdominal organs and structures. It is more commonly used for liver, gallbladder, kidney, or spleen disorders.

Choice D reason: Computed tomography (CT) scan with contrast is not a diagnostic test for diverticulosis. It is an invasive imaging technique that uses x-rays and a contrast dye to create cross-sectional images of the body. It is more commonly used for detecting tumors, abscesses, or bleeding. It is also used for diagnosing diverticulitis, which is the inflammation or infection of the diverticula.

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