An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal, "Increase daily intake of fluids." Which nursing intervention is most useful in assisting the resident to meet this goal?

Record the client's intake and output every shift.

Offer a glass of fluid every hour while awake.

Increase fluids provided with the client's meals.

Maintain a full pitcher of water at the bedside.

Answer and Explanation

The Correct Answer is B

A.   Record the client's intake and output every shift: While important for monitoring fluid balance, this intervention does not directly facilitate increased fluid intake.
B.   Offer a glass of fluid every hour while awake: This intervention ensures regular and frequent opportunities for the resident to consume fluids, which can help increase overall intake.
C.   Increase fluids provided with the client's meals: While this may help increase fluid intake, relying solely on meals may not be sufficient, especially if the resident does not finish their meals.
D.   Maintain a full pitcher of water at the bedside: While having water readily available is important, relying solely on this may not ensure regular intake throughout the day.

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Correct Answer is D

Explanation

- A) Any level of fever is not necessarily serious after vaccination. Mild fever is a common side effect and can be monitored at home unless it exceeds 101 degrees Fahrenheit or persists beyond 48 hours.
- B) Keeping the child home from daycare is not necessary unless the child develops symptoms that warrant closer observation or care, such as a high fever or behavioral changes.
- C) Aspirin should not be given to children due to the risk of Reye's syndrome, a rare but serious condition that can cause swelling in the liver and brain.
- D) Applying a cool pack to the injection site is a safe and effective way to reduce discomfort and swelling that may occur after the vaccination.

A. Prepare to prevent respiratory or cardiac arrest B. Stop infusion of magnesium C. Increase IV fluids D. Obtain serum magnesium level E. Administer oxygen F. Obtain blood pressure G. Administer calcium gluconate

Correct Answer is ["A","B","D","E","G"]

Explanation

A. Prepare to prevent respiratory or cardiac arrest: The client's decreased level of consciousness and respiratory rate of 10 breaths/minute indicate a potential risk for respiratory or cardiac arrest. Immediate measures to maintain airway patency and support ventilation may be necessary.
B. Stop infusion of magnesium: The client's decreased level of consciousness and absent deep tendon reflexes (DTR) bilaterally are signs of magnesium toxicity. Stopping the infusion of magnesium sulfate is essential to prevent further complications.
C. Increasing IV fluids is not a priority in management of magnesium toxicity.
D. Obtain serum magnesium level: With signs of magnesium toxicity, obtaining a serum magnesium level is necessary to confirm the diagnosis and guide further management.
E. Administer oxygen: The client's oxygen saturation of 93% on room air indicates hypoxemia.
Administering oxygen via nasal cannula to maintain oxygen saturation greater than 96% helps prevent further respiratory compromise.
F. Obtaining blood pressure is not a priority.
G. Administer calcium gluconate: Calcium gluconate is the antidote for magnesium toxicity.
Since the client is showing signs of magnesium toxicity (decreased level of consciousness and absent DTRs), administering calcium gluconate is necessary to counteract the effects of magnesium
H. Caesarian delivery is not part of management for magnesium toicity.

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An older resident of an extended care facility has recurrent urinary tract infections. The nursing care plan includes the goal, "Increase daily intake of fluids." Which nursing intervention is most useful in assisting the resident to meet this goal?

Nursing Test Bank

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Explanation

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