A nurse is planning care for an older adult client who has manifestations of dehydration. Which of the following interventions should the nurse include in the plan?
Offer oral fluids every 4 hr.
Monitor the client's hemoglobin level.
Check urinary output status every 4 hr.
Administer furosemide IV.
The Correct Answer is C
A. Offer oral fluids every 4 hr: Offering oral fluids every 4 hours may not be frequent enough for a client with dehydration. The nurse should encourage the client to drink fluids more regularly (e.g., every 1-2 hours) to help prevent further dehydration.
B. Monitor the client's hemoglobin level: Monitoring the hemoglobin level is not a priority intervention for managing dehydration. The focus should be on fluid replacement and monitoring indicators of dehydration, such as urine output.
C. Check urinary output status every 4 hr: Monitoring urinary output regularly is crucial for assessing hydration status. Dehydration often leads to reduced urine output, and it is important to check for changes in output to adjust fluid intake and assess the effectiveness of interventions.
D. Administer furosemide IV: Furosemide is a diuretic, which increases urine output. Administering it to a client who is dehydrated would worsen their dehydration and is contraindicated. The focus should be on rehydration, not on further increasing fluid loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hyponatremia: While hyponatremia can cause neurological symptoms, such as confusion and seizures, it is not typically associated with a positive Trousseau's sign. Trousseau's sign is more specifically related to calcium imbalances.
B. Hypocalcemia: A positive Trousseau's sign (a spasm of the hand and wrist when a blood pressure cuff is inflated) is a classic sign of hypocalcemia, which is low calcium levels in the blood. Numbness and tingling of the toes (paresthesia) are also common symptoms of hypocalcemia.
C. Hyperkalemia: Hyperkalemia typically causes muscle weakness, fatigue, and potential cardiac arrhythmias, but it does not directly cause a positive Trousseau's sign or numbness and tingling in the extremities.
D. Hypermagnesemia: Hypermagnesemia (high magnesium levels) typically causes symptoms such as muscle weakness, respiratory depression, and hypotension. It is not associated with a positive Trousseau's sign.
Correct Answer is B
Explanation
A. Water pitcher on client's bedside table: Water does not require special handling after chemotherapy. The nurse should ensure that the client has access to clean drinking water, but there are no special precautions for handling it.
B. Client's urine in the bedside commode: Client's urine after chemotherapy requires special handling, as it may contain cytotoxic drugs or their metabolites for up to 48 hours. Proper precautions, such as wearing gloves and using appropriate disposal methods, are necessary to avoid exposure.
C. Client's bed linens after use: Bed linens do not require special handling unless contaminated with bodily fluids such as urine or vomit that could contain chemotherapy drugs. Gloves should be worn, but no additional precautions are required unless the linens are contaminated.
D. Food tray and utensils from client's breakfast: Food trays and utensils do not require special handling after chemotherapy unless they are contaminated with body fluids. Normal cleaning and sanitation practices are sufficient.
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