A nurse is planning care for a client who has hypocalcemia. Which of the following interventions should the nurse include in the plan?

The correct answer is: c. Crackles in the lungs

Choice A: Dry mucous membranes

Reason: Dry mucous membranes are typically associated with dehydration, not fluid overload. In fluid overload, the body retains excess fluid, leading to symptoms such as edema and pulmonary congestion, rather than dryness of mucous membranes.

Choice B: Decreased urine output

Reason: Decreased urine output can occur in conditions like dehydration or renal failure. In fluid overload due to heart failure, the kidneys may initially try to excrete excess fluid, leading to increased urine output. However, as heart failure progresses, renal perfusion may decrease, potentially leading to reduced urine output. This is not a primary or consistent symptom of fluid overload.

Choice C: Crackles in the lungs

Reason: Crackles in the lungs are a hallmark sign of fluid overload, particularly in the context of heart failure. This occurs due to pulmonary edema, where excess fluid accumulates in the alveoli, causing the characteristic crackling sound during auscultation. This is a direct result of the heart’s inability to effectively pump blood, leading to fluid backing up into the lungs.

Choice D: Hypotension

Reason: Hypotension, or low blood pressure, is not typically associated with fluid overload. In fact, fluid overload can often lead to hypertension (high blood pressure) due to the increased volume of fluid in the circulatory system. Hypotension might occur in severe heart failure if the heart’s pumping ability is significantly compromised, but it is not a primary manifestation of fluid overload.

Choice A reason:

Aspirin or other salicylates can cause metabolic acidosis, not respiratory alkalosis, by increasing the production of organic acids and interfering with bicarbonate reabsorption in the kidneys.

Choice B reason:

Breathing into a paper bag when feeling anxious can help prevent or treat respiratory alkalosis by increasing the carbon dioxide levels in the blood and lowering the pH. Anxiety can cause respiratory alkalosis by stimulating hyperventilation, which decreases the carbon dioxide levels in the blood and raises the pH.

Choice C reason:

Drinking more fluids to prevent dehydration can help prevent or treat metabolic alkalosis, not respiratory alkalosis, by increasing the renal excretion of bicarbonate and lowering the pH. Dehydration can cause metabolic alkalosis by decreasing the renal excretion of bicarbonate and raising the pH.

Choice D reason:

Monitoring blood sugar levels regularly can help prevent or treat diabetic ketoacidosis, which is a type of metabolic acidosis, not respiratory alkalosis, by increasing the production of ketone bodies and lowering the pH. Diabetic ketoacidosis can occur when there is insufficient insulin to metabolize glucose and the body resorts to fat breakdown for energy.