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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Based on the given documentation, the nurse suspects that the client has respiratory alkalosis. The client's ABG results show a pH of 7.52, which indicates alkalosis and the PaO2 level is slightly low, suggesting respiratory involvement. Rapid breathing (RR44) and wheezing also support the possibility of respiratory alkalosis.
Correct Answer is B
Explanation
This response acknowledges the patient's concerns and provides reassurance that the changes are temporary and will improve after surgery. Response is dismissive of the patient's concerns and may make the patient feel unheard. Response c may be helpful, but it does not address the patient's emotional concerns. Response d is not accurate because the patient has expressed feeling awful about their appearance.
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