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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Related Questions
Correct Answer is B
Explanation
A. Furosemide (Lasix) is a loop diuretic that typically causes the loss of potassium through the urine, thus putting clients at risk for hypokalemia, not hyperkalemia.
B. Spironolactone (Aldactone) is a potassium-sparing diuretic, meaning it helps the body retain potassium. As a result, it can lead to hyperkalemia, especially in patients with kidney dysfunction or when used with other medications that increase potassium levels.
C. Sodium polystyrene sulfate (Kayexalate) is used to treat hyperkalemia by exchanging sodium for potassium in the intestines, thus lowering potassium levels. It does not contribute to hyperkalemia.
D. Insulin does not directly cause hyperkalemia; in fact, insulin administration can lower potassium levels by driving potassium into cells.
Correct Answer is B
Explanation
A. Decreased urine output is not directly associated with elevated potassium levels. It is more commonly linked to renal failure or dehydration.
B. Hyperkalemia (high potassium levels) can lead to ascending muscle paralysis due to its effects on the neuromuscular system. Potassium is critical for proper muscle function, and elevated levels can disrupt the electrical impulses needed for muscle contraction, potentially causing paralysis.
C. Hypoglycemia is unrelated to elevated potassium levels. It is more often associated with insulin use, inadequate food intake, or certain medical conditions.
D. Ascites is fluid accumulation in the abdomen, usually caused by liver disease or heart failure, and is not a direct complication of hyperkalemia.
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