The nurse is caring for a client with a diagnosis of hypervolemia. Which intervention is the priority for the nurse to implement?
Administer medications that promote fluid retention
Administer diuretics
Encourage increased fluid intake to dilute electrolytes
Monitor daily weights
The Correct Answer is B
Choice A reason: Administering medications that promote fluid retention, like vasopressin, worsens hypervolemia by increasing water reabsorption, exacerbating edema and hypertension. This is contraindicated, as the goal is fluid removal, making this an incorrect intervention for managing excess fluid volume in hypervolemia.
Choice B reason: Administering diuretics is the priority in hypervolemia, promoting renal excretion of excess fluid, reducing edema, pulmonary congestion, and hypertension. Diuretics like furosemide correct fluid overload, preventing complications like heart failure exacerbation, making this the most critical intervention for immediate fluid management.
Choice C reason: Encouraging increased fluid intake worsens hypervolemia by adding to excess fluid, increasing pulmonary edema and heart failure risks. The goal is to remove fluid, not add it, making this inappropriate compared to diuretics, which directly address fluid overload in this condition.
Choice D reason: Monitoring daily weights tracks fluid status but is not an intervention. While useful for assessing treatment response, it does not reduce fluid volume like diuretics, which prevent complications, making weight monitoring a supportive, not primary, action in hypervolemia management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A sodium level of 121 mEq/L indicates severe hyponatremia, risking seizures due to cerebral edema from low osmolality. Seizure precautions (e.g., padded rails, anticonvulsants) protect from injury during potential seizures, making this the priority to ensure safety before correcting sodium levels.
Choice B reason: Educating on high-sodium foods is a long-term strategy for hyponatremia but not the priority. Severe hyponatremia (121 mEq/L) risks seizures, requiring immediate protective measures like seizure precautions over dietary education, which addresses chronic management rather than acute neurological risks.
Choice C reason: Administering 3% sodium chloride corrects hyponatremia but is not the first priority. Rapid correction risks osmotic demyelination, and seizure precautions are needed to protect against cerebral edema-induced seizures, a more immediate risk in severe hyponatremia, before initiating sodium therapy.
Choice D reason: A 1-liter-per-day fluid restriction addresses fluid overload in hyponatremia but is secondary to seizure precautions. Severe hyponatremia (121 mEq/L) risks neurological complications like seizures, making immediate safety measures the priority over fluid restriction, which is a slower corrective strategy.
Correct Answer is B
Explanation
Choice A reason: Increased respiratory rate suggests persistent respiratory distress or ineffective airway clearance in pneumonia, as the body compensates for hypoxia or hypercapnia. This indicates ongoing secretions or inflammation, not a therapeutic response, making it an incorrect indicator compared to clear lung sounds.
Choice B reason: Clear lung sounds indicate effective airway clearance in pneumonia, as treatments like antibiotics and chest physiotherapy reduce secretions and inflammation, allowing normal air movement. This reflects resolved airway obstruction and improved gas exchange, making it the best indicator of a therapeutic response to treatment.
Choice C reason: Brisk capillary refill reflects adequate peripheral perfusion but is unrelated to airway clearance in pneumonia. It does not indicate resolution of secretions or improved lung function, making it an irrelevant marker for evaluating treatment response compared to clear lung sounds, which directly assess airway patency.
Choice D reason: Decreased pleuritic pain suggests reduced pleural inflammation but does not confirm airway clearance. Pain reduction may occur without clearing secretions, the primary issue in pneumonia. Clear lung sounds better indicate successful treatment by demonstrating unobstructed airways and improved respiratory function.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.