Which nursing measure should a nurse include in the care plan to encourage a client to increase fluid intake?
Placing a fresh water pitcher on the bedside table.
Offering frequent servings of preferred fluids.
Explaining the problems of inadequate intake.
Stressing the importance of drinking fluids.
The Correct Answer is B
This is because offering fluids that the client likes and in small amounts can help increase the client’s fluid intake and prevent dehydration. According to, some other nursing measures that can help improve the client’s nutritional intake are:
- Encouraging favorite foods from home, when possible.
- Providing frequent oral hygiene.
- Providing a pleasant environment during mealtime.
- Providing assistance with eating, if needed.
Choice A is wrong because placing a freshwater pitcher on the bedside table may not be enough to motivate the client to drink more fluids, especially if the client does not like plain water or has difficulty reaching for the pitcher.
Choice C is wrong because explaining the problems of inadequate intake may not be effective in changing the client’s behavior, and may even cause anxiety or resentment.
Choice D is wrong because stressing the importance of drinking fluids may also be ineffective or counterproductive, as it may sound like nagging or lecturing to the client.
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Correct Answer is D
Explanation
This is because helping the client to recognize and avoid situations that cause anxiety can reduce the frequency and severity of acute anxiety episodes. According to , a nurse should encourage the client to verbalize feelings and provide a calm and supportive environment.
Choice A is wrong because isolating the client when there are observable physiologic symptoms of anxiety can increase the client’s sense of fear and loneliness.
The nurse should stay with the client and offer reassurance and comfort.
Choice B is wrong because ignoring the client’s behavior as obvious attempts to gain attention can make the client feel rejected and misunderstood.
The nurse should acknowledge the client’s feelings and provide empathy and support.
Choice C is wrong because reducing all stress whenever the client seems anxious can prevent the client from learning coping skills and developing resilience.
The nurse should help the client to identify healthy ways of managing stress and anxiety.
Correct Answer is D
Explanation
The needle gauge size for subcutaneous injections should be between 25 and 31, depending on the patient’s size and the viscosity of the medication.
A smaller gauge number means a larger diameter needle, which can cause more pain and tissue damage.
Choice A is wrong because 8 is too large for subcutaneous injections and can cause bleeding and bruising.
Choice B is wrong because 20 is also too large for subcutaneous injections and can cause similar complications as choice A.
Choice C is wrong because 21 is still too large for subcutaneous injections and can cause discomfort and injury to the patient.
The needle length for subcutaneous injections should be between ½ inch and ⅝ inch, depending on the amount of subcutaneous tissue present. The nurse should pinch the skin and insert the needle at a 45-degree angle to ensure proper delivery of the medication.
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