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 B

Explanation

A. Instructing the UAP to obtain a blood glucose level could be useful, but the nurse should prioritize assessing the client directly.
B. Assessing the client is the first step to confirm hypoglycemia and determine the severity, allowing for appropriate intervention.
C. Administering orange juice may be appropriate after confirming hypoglycemia, but an assessment should be performed first.
D. Administering dextrose is a severe intervention used when symptoms are extreme; assessment should occur first.

A. Darbepoetin alfa B. Lactulose C. Sevelamer D. Sodium polystyrene

Correct Answer is D

Explanation

A. Darbepoetin alfa is used to treat anemia, particularly in chronic kidney disease, but does not address hyperkalemia.
B. Lactulose is used to reduce ammonia levels in hepatic encephalopathy, not to lower potassium levels.
C. Sevelamer is a phosphate binder and does not affect potassium levels.
D. Sodium polystyrene (Kayexalate) is used to treat hyperkalemia by promoting potassium excretion through the gastrointestinal tract.

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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

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