The nurse is caring for a patient with hypothermia and fluid volume excess. Which of the following would be included in the plan of care?
Fluid restriction
Administration of hypotonic IV fluids
Placement of an indwelling urinary catheter
Administration Of action-exchange resin
The Correct Answer is A
The plan of care for a patient with hypothermia and fluid volume excess would typically include measures to increase the patient's body temperature and decrease their fluid volume. Therefore, option a (fluid restriction) would be appropriate for this patient.
Options b (administration of hypotonic IV fluids) and d (administration of ion-exchange resin) would not be appropriate because they would increase the patient's fluid volume rather than decrease it.
Option c (placement of an indwelling urinary catheter) may be appropriate to closely monitor the patient's urine output, which is an important indicator of their fluid status. However, this alone would not be sufficient to manage the patient's hypothermia and fluid volume excess.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Clients with acute gastritis are recommended to eat smaller, frequent meals instead of three large meals. This helps to reduce the workload on the digestive system and allows the stomach to heal. Therefore, option A is not a suitable nursing intervention for a client with acute gastritis.
Options b, c, and d are all appropriate nursing interventions for a client with acute gastritis. Observing stool characteristics can help to identify any bleeding or inflammation in the gastrointestinal tract, evaluating intake and output can help to identify any fluid imbalances, and monitoring laboratory reports of electrolytes can help to identify any imbalances that may occur because of vomiting or diarrhea.
Correct Answer is D
Explanation
Coffee-ground material in the NG suction indicates that there is active bleeding in the upper gastrointestinal tract, which could be a life-threatening situation. This requires immediate medical attention and intervention to control the bleeding and stabilize the patient.
Options A, B, and C are also important assessment data, but they are not as urgent as option D in this scenario.
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