A patient has had diarrhea for several days. What assessment will the nurse make to identify risks from the diarrhea?

A. Administration of hypotonic fluids: Hypotonic fluids would worsen hyponatremia by further diluting the sodium concentration in the blood. This intervention is contraindicated in patients with both low sodium levels and fluid overload.

B. Placement of an indwelling catheter: While a catheter may be used for monitoring output, it does not address fluid volume excess or hyponatremia. Invasive devices should only be used when clinically necessary and not as a primary treatment.

C. Administration of calcium gluconate: Calcium gluconate is used to manage hyperkalemia or hypocalcemia, not hyponatremia. It has no therapeutic effect in correcting sodium imbalance or fluid volume excess.

D. Fluid restriction: Restricting fluids is the appropriate treatment for a patient with hyponatremia and fluid overload. It helps prevent further dilution of sodium and reduces excess fluid in the body, aiding in restoring balance.

A. Apply supplemental oxygen by face mask as needed: While oxygen therapy may be necessary for a client with pneumonia, it is a treatment intervention rather than an assessment activity. The nurse must first gather assessment data before deciding on interventions.

B. Document "impaired oxygenation" on the nursing care plan: This pertains to the diagnosis and planning phase of the nursing process. It is based on assessment findings and does not constitute an assessment activity in itself.

C. Collaborate with the client to form goals: This is part of the planning phase and involves setting mutually agreed-upon outcomes, which occurs after the assessment has been conducted.

D. Auscultate the chest for breath sounds: By listening to the lung fields, the nurse can detect abnormal sounds such as crackles or diminished breath sounds, which are commonly associated with pneumonia. This provides critical information about respiratory status and helps guide further care.