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 A

Explanation

Choice A reason: Fried chicken is a food that the nurse should tell the client to avoid eating. Fried chicken is high in fat, which can trigger or worsen the symptoms of GERD. Fat can relax the lower esophageal sphincter, which is the muscle that prevents the stomach acid from flowing back into the esophagus. Fat can also delay the stomach emptying, which can increase the pressure and acid production in the stomach.

Choice B reason: Nonfat milk is not a food that the nurse should tell the client to avoid eating. Nonfat milk is low in fat, which can help prevent or reduce the symptoms of GERD. Nonfat milk can also provide calcium and protein, which are essential nutrients for the client's health.

Choice C reason: Bananas are not a food that the nurse should tell the client to avoid eating. Bananas are low in acid, which can help neutralize the stomach acid and soothe the esophagus. Bananas are also rich in fiber, which can promote digestion and prevent constipation.

Choice D reason: Oatmeal is not a food that the nurse should tell the client to avoid eating. Oatmeal is a whole grain that is low in fat and high in fiber, which can help prevent or reduce the symptoms of GERD. Oatmeal can also absorb the excess acid in the stomach and prevent it from refluxing into the esophagus.

A. Pyuria B. Weight loss C. Jugular vein distention D. Muscle contractions

Correct Answer is C

Explanation

Choice A reason: Pyuria, or pus in the urine, is not a direct sign of fluid volume overload. It may indicate a urinary tract infection, kidney stones, or other renal problems.

Choice B reason: Weight loss is not a typical finding of fluid volume overload. In fact, weight gain is a common symptom of fluid retention, as the body holds more fluid than it excretes.

Choice C reason: Jugular vein distention, or the bulging of the neck veins, is a serious indicator of fluid volume overload. It reflects increased pressure in the right side of the heart and the systemic circulation. It may also signal heart failure, pulmonary hypertension, or pericardial tamponade.

Choice D reason: Muscle contractions are not directly related to fluid volume overload. They may be caused by electrolyte imbalances, dehydration, muscle fatigue, or nerve disorders.

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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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