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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: Lactated Ringer’s (130 mEq/L sodium) is isotonic but insufficient for severe hyponatremia (120 mEq/L). It may worsen fluid overload without rapidly raising sodium, risking neurological complications like seizures, making it inappropriate for urgent correction compared to hypertonic saline.

Choice B reason: Dextrose 5% in 0.9% sodium chloride (154 mEq/L sodium) is isotonic but inadequate for severe hyponatremia. It raises sodium slowly, risking persistent neurological symptoms. Hypertonic saline (3%) corrects sodium faster, preventing complications like cerebral edema, making this a less effective choice.

Choice C reason: 0.45% sodium chloride (77 mEq/L sodium) is hypotonic, worsening hyponatremia by diluting serum sodium. This exacerbates neurological risks like seizures in a client with 120 mEq/L, making it an incorrect choice for correcting severe hyponatremia compared to hypertonic saline.

Choice D reason: 3% sodium chloride (513 mEq/L sodium) is hypertonic, ideal for correcting severe hyponatremia (120 mEq/L). It raises sodium gradually, preventing seizures or cerebral edema. Careful administration avoids rapid correction risks like osmotic demyelination, making it the appropriate choice for this client’s condition.

A. Client blood pressure 118/70 B. Client reports pain severity 6/10 C. Client appears anxious when family arrives D. Client requests information about pain medications

Correct Answer is B

Explanation

Choice A reason: Blood pressure 118/70 is normal, indicating stable hemodynamics. Pain (6/10) is more urgent, as uncontrolled pain increases stress hormones, impairing healing and risking complications like atelectasis, making blood pressure a lower priority in this postoperative scenario.

Choice B reason: Pain severity of 6/10 is a priority, as moderate postoperative pain increases catecholamine release, impairing healing and raising risks of complications like atelectasis or hypertension. Prompt pain management improves recovery, preventing physiological stress, making this the most urgent issue to address.

Choice C reason: Anxiety when family arrives is psychosocial but less urgent than pain (6/10). Pain causes physiological stress, increasing risks like impaired healing or respiratory complications, while anxiety’s impact is less immediate, making it secondary to effective pain management.

Choice D reason: Requesting pain medication information indicates a need for education but is less urgent than addressing pain (6/10). Uncontrolled pain risks physiological complications like increased heart rate or poor healing, making pain management the priority over providing medication information.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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