The nurse is educating a client at risk for hypervolemia for self-management at home. Which statement by the client indicates a need for further teaching?
I will decrease the amount of fluids I drink each day.
I will avoid foods high in sodium.
I will weigh myself once a week on the same scale.
I will call the physician’s office if swelling occurs.
The Correct Answer is C
Choice A reason: Decreasing fluid intake is appropriate for hypervolemia, as excess fluid exacerbates conditions like heart failure, causing edema and hypertension. Limiting fluids reduces fluid overload, preventing complications like pulmonary edema, indicating the client understands this aspect, requiring no further teaching on this point.
Choice B reason: Avoiding high-sodium foods is correct, as sodium retains water, worsening hypervolemia. Reducing sodium prevents fluid retention, lowering risks of edema and heart failure exacerbation, showing the client understands this self-management strategy, making further teaching unnecessary for this aspect of hypervolemia care.
Choice C reason: Weighing oneself weekly is inadequate for hypervolemia, as daily monitoring detects early fluid retention (2-3 pounds). Sudden weight gain signals worsening fluid overload, risking pulmonary edema. This statement indicates a need for further teaching on the importance of daily weights to manage hypervolemia effectively.
Choice D reason: Calling the physician for swelling is appropriate, as edema indicates fluid retention in hypervolemia. Prompt reporting allows early intervention to prevent complications like heart failure, showing the client understands this action, requiring no further teaching on reporting symptoms for timely medical management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: A Jackson-Pratt drain removes serous fluid and blood from the surgical site, preventing seromas, hematomas, or infections. By maintaining a closed suction system, it promotes wound healing and reduces complications, making this the primary purpose of the JP drain in postoperative care.
Choice B reason: While a JP drain may remove small amounts of blood, its primary purpose is preventing fluid accumulation, not limiting bleeding. Bleeding control is managed intraoperatively or with other measures, making this a secondary, less accurate purpose of the drain compared to fluid prevention.
Choice C reason: A JP drain is not used for medication administration. It is a closed suction system designed to remove fluid from the surgical site to prevent complications. Medications are given via other routes (e.g., IV), making this an incorrect description of the drain’s purpose.
Choice D reason: A JP drain does not eliminate the need for wound irrigations, which clean wounds directly. The drain prevents fluid buildup in closed surgical sites, reducing infection risk, but it does not replace irrigation, which addresses different wound care needs, making this choice incorrect.
Correct Answer is C
Explanation
Choice A reason: Blood pressure of 94/62 mm Hg indicates hypotension, possibly from hypovolemia or anesthesia, but is less life-threatening than hypoxia. Oxygen saturation of 82% risks organ damage, making blood pressure secondary, requiring fluid or vasopressor support after addressing hypoxia.
Choice B reason: Heart rate of 110 beats/minute (tachycardia) suggests compensation for hypovolemia or pain but is less critical than oxygen saturation of 82%. Hypoxia risks rapid organ damage, while tachycardia is addressed after oxygenation, making it a lower priority in postoperative assessment.
Choice C reason: Oxygen saturation of 82% indicates severe hypoxia, risking brain and organ damage within minutes. Postoperative clients are prone to atelectasis or pulmonary edema, impairing gas exchange. Immediate oxygen therapy or airway management is critical, making this the most urgent finding.
Choice D reason: Urine output of 50 mL/hr is normal (0.5–1 mL/kg/hr), indicating adequate renal perfusion. Unlike oxygen saturation of 82%, which signals critical hypoxia, normal urine output does not require immediate attention, reflecting stable hydration and kidney function.
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