A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?
Administer furosemide to the client.
Educate the client that oral fluids are not necessary.
Monitor the client's weight once a week.
Monitor the client's IV site and infusion.
The Correct Answer is D
A. Administering furosemide (a diuretic) would worsen dehydration and is contraindicated in this scenario. The goal is to rehydrate the client, not to promote fluid loss.
B. Educating the client that oral fluids are not necessary is incorrect. Oral fluids are important for rehydration, and the client should be encouraged to drink fluids unless contraindicated.
C. Monitoring the client's weight once a week is not sufficient for assessing dehydration status. More frequent monitoring is needed to assess the effectiveness of treatment.
D. Monitoring the client's IV site and infusion is essential to ensure that the IV is patent, the fluid is being infused properly, and there are no complications such as infiltration or infection. This is a key aspect of nursing care for clients receiving IV fluids.
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Correct Answer is D
Explanation
A. Administering furosemide (a diuretic) would worsen dehydration and is contraindicated in this scenario. The goal is to rehydrate the client, not to promote fluid loss.
B. Educating the client that oral fluids are not necessary is incorrect. Oral fluids are important for rehydration, and the client should be encouraged to drink fluids unless contraindicated.
C. Monitoring the client's weight once a week is not sufficient for assessing dehydration status. More frequent monitoring is needed to assess the effectiveness of treatment.
D. Monitoring the client's IV site and infusion is essential to ensure that the IV is patent, the fluid is being infused properly, and there are no complications such as infiltration or infection. This is a key aspect of nursing care for clients receiving IV fluids.
Correct Answer is B
Explanation
A. Hypertonic fluids are not contraindicated in patients with cerebral edema. In fact, they are often used to reduce cerebral swelling by drawing fluid out of the brain tissue into the bloodstream.
B. Hypertonic saline (3%) is used to shift fluid out of brain tissue in conditions such as cerebral edema. It creates an osmotic gradient, pulling water from the intracellular space into the extracellular and vascular compartments, reducing intracranial pressure.
C. Hypertonic saline is not used for clients with hypernatremia because it would exacerbate the condition by further increasing sodium levels.
D. Hypertonic fluids do not promote hydration of brain tissue. Instead, they work to reduce excess fluid in the brain by creating an osmotic effect.
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