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 ["5"]
Explanation
Step 1 is (2 grams ÷ 10 mL) Result = 0.2 grams per mL
Step 2 is (1 gram ÷ 0.2 grams per mL) Result = 5 mL
Correct Answer is C
Explanation
Choice A reason: Hypoactive bowel sounds in two quadrants suggest reduced peristalsis, indicating persistent postoperative ileus rather than resolution. Normal peristalsis produces active bowel sounds across all quadrants, making this an incorrect indicator of returned gastrointestinal motility in a postoperative client.
Choice B reason: Requesting food indicates appetite but not necessarily peristalsis. Appetite can return before gastrointestinal motility, driven by neurological and hormonal factors. Passage of flatus directly confirms intestinal motility, making appetite a less accurate indicator of peristalsis restoration in this context.
Choice C reason: Passage of flatus is the most accurate indicator of returned peristalsis, as it reflects gastrointestinal motility. Gas movement through the intestines, expelled as flatus, confirms resolution of postoperative ileus, indicating normal bowel function, making this the best sign of recovery.
Choice D reason: Abdominal distention suggests gas accumulation, indicating persistent ileus rather than returned peristalsis. Gas buildup occurs when motility is impaired, causing bloating. Passage of flatus confirms gas movement and restored motility, making distention an incorrect indicator of recovery.
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