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. Checking urine for ketones is more relevant in DKA, not HHNS, as HHNS typically does not involve ketone production.
B. When blood glucose drops significantly, insulin infusion rates are usually decreased to prevent hypoglycemia and a rapid fall in glucose levels.
C. Increasing the insulin drip could cause hypoglycemia, as the client’s glucose is already decreasing.
D. A regular meal can be given when the client’s glucose levels are more stable and controlled, but meal timing should be coordinated with insulin adjustments.

A. "Pull back on the plunger after injecting the insulin." B. "Store the current bottle of insulin at room temperature." C. "Massage the injection site after removing the needle." D. "Use each syringe up to six times."

Correct Answer is B

Explanation

A. Pulling back on the plunger after injecting insulin is incorrect and could cause the medication to leak out, leading to inadequate dosing.
B. Storing the current bottle of insulin at room temperature (if not in use) helps maintain the insulin's effectiveness and reduces discomfort during injections.
C. Massaging the injection site is not recommended as it can cause the insulin to absorb too quickly and lead to variable blood sugar levels.
D. Each syringe should only be used once to prevent contamination and ensure accurate dosing.

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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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