The nurse documents that the client has a problem of fluid volume excess (FVE). Which intervention should the nurse include in the plan of care? Select all that apply.

Monitor blood glucose levels

Weigh the client daily

Prepare the client for hemodialysis

Restrict sodium in the client's diet

Change the IV fluid from 0.9% NS to D5W

Answer and Explanation

Correct Answer : B,D

A. Monitoring blood glucose levels is not directly related to managing fluid volume excess.
B. Weighing the client daily is essential for monitoring fluid retention and the effectiveness of interventions.
C. Preparing for hemodialysis is only necessary for severe fluid overload unresponsive to other treatments.
D. Restricting sodium in the diet helps prevent further fluid retention and supports management of FVE.
E. Changing IV fluids to D5W is not appropriate, as it could exacerbate fluid volume excess by increasing fluid load.

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Correct Answer is ["A","C","D","E"]

Explanation

A. Monofilament testing is recommended to assess for peripheral neuropathy, a common complication in diabetes.
B. Hearing exams are not specifically indicated as part of annual diabetes care.
C. Serum creatinine is monitored to assess kidney function, as diabetes can lead to kidney disease.
D. Testing urine for microalbumin detects early signs of kidney damage.
E. HbA1c provides information about long-term glucose control and is a key indicator in managing diabetes complications.

A. Start IV 0.9% Sodium Chloride B. Assess for bowel sounds C. Start 02 at 2L/min D. Assess lab value for potassium

Correct Answer is B

Explanation

A. Starting IV 0.9% sodium chloride may be necessary for hydration but is not a priority action before administering Kayexalate.
B. Assessing for bowel sounds is essential because Kayexalate works by exchanging potassium for sodium in the intestine, and bowel motility must be adequate to ensure the medication is effective and to prevent complications such as bowel obstruction.
C. Starting oxygen is unnecessary unless the patient exhibits signs of respiratory distress, which is not indicated here.
D. While checking potassium levels is important, it is often done as part of the initial assessment and does not need to be repeated immediately before administering Kayexalate if levels were already assessed and are high.

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The nurse documents that the client has a problem of fluid volume excess (FVE). Which intervention should the nurse include in the plan of care? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

To monitor for complications in a patient with type II diabetes, the healthcare provider will write a prescription for the client to schedule which of the following tests at least annually? Select all that apply.

Correct Answer is ["A","C","D","E"]

Explanation

A patient is transferred to the emergency department from the outpatient clinic with a diagnosis of hyperkalemia. Kayexalate was prescribed. Which of the following nursing actions will the nurse perform before administering Kayexalate?

Correct Answer is B

Explanation

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