A nurse is assisting in the plan of care for a client who has dehydration and hypotension. Which of the following actions should the nurse plan to take?
Encourage the client to use guided imagery to relax.
Elevate the head of the client's bed.
Increase the client's fluid intake.
Instruct the client to perform the Valsalva maneuver.
Instruct the client to perform the Valsalva maneuver.
The Correct Answer is C
Choice A reason : Guided imagery is a relaxation technique that can help reduce stress and anxiety, but it does not directly address the physiological issues of dehydration and hypotension. While it may be beneficial as a complementary therapy, it is not the primary intervention for a patient suffering from these conditions.
Choice B reason : Elevating the head of the bed is generally recommended for patients who have difficulty breathing or to prevent aspiration, but it is not the standard care for hypotension. In fact, for a hypotensive patient, elevating the legs might be more beneficial to promote venous return to the heart⁹[^20^].
Choice C reason : Increasing fluid intake is the most direct and effective way to treat dehydration. When a patient is hypotensive, it often indicates a low blood volume, which can be improved by increasing fluid intake. This can be done orally if the patient is conscious and able to drink, or intravenously if they are not. The normal range for blood pressure is 90/60 mmHg to 120/80 mmHg, and maintaining adequate hydration helps to ensure blood pressure stays within this range⁸.
Choice D reason : The Valsalva maneuver is a technique used to potentially correct certain types of abnormal heart rhythms, particularly supraventricular tachycardia, and not for treating hypotension or dehydration. It involves increasing intrathoracic pressure by exhaling forcefully with a closed airway, which can have various effects on the cardiovascular system. However, it is not an appropriate intervention for a dehydrated, hypotensive patient⁹[^10^].
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Pain assessment is a critical priority for postoperative patients. After aortic valve replacement surgery, patients may experience discomfort or pain related to the incision site, chest tube placement, or other surgical interventions. Pain assessment allows the nurse to evaluate the effectiveness of pain management strategies, adjust medications as needed, and ensure the patient's comfort and well-being. Pain can also impact vital signs and overall recovery, so addressing it promptly is essential.
Choice B reason: Monitoring blood pressure is important, but it is not the highest priority immediately after surgery. Blood pressure assessment is part of routine postoperative care, but it does not directly address the patient's immediate comfort or potential complications. However, if the patient's blood pressure becomes significantly abnormal, it would require immediate attention.
Choice C reason: Checking bowel sounds is relevant for assessing gastrointestinal function, but it is not the top priority immediately postoperatively. Bowel sounds may be diminished initially due to anesthesia, surgical manipulation, or bowel rest. However, assessing pain and other vital signs takes precedence over bowel sounds in the immediate recovery period.
Choice D reason: Assessing the catheter insertion site is essential, especially if the patient has an indwelling urinary catheter. However, it is not the highest priority immediately after aortic valve replacement. Pain assessment and monitoring for complications related to surgery (such as bleeding, infection, or cardiac issues) take precedence. The catheter site can be assessed during routine nursing care.
Correct Answer is ["A","C","D"]
Explanation
Choice A reason : Dyspnea, or difficulty breathing, is a common symptom of left-sided heart failure. It occurs because the heart is unable to pump efficiently, leading to a backup of fluid in the lungs, which can cause shortness of breath.
Choice B reason : Jugular vein distention is typically associated with right-sided heart failure, not left-sided. It occurs when there is an increased pressure in the right atrium, leading to visible bulging of the neck veins.
Choice C reason : Orthopnea, or difficulty breathing while lying flat, is another symptom of left-sided heart failure. Fluid accumulation in the lungs makes it difficult for the patient to breathe without elevation, hence they may need to sleep with extra pillows.
Choice D reason : Crackles, which are heard during lung auscultation, are indicative of fluid accumulation in the alveoli due to the inefficiency of the left side of the heart to pump blood, leading to pulmonary congestion.
Choice E reason : Tachycardia, or rapid heartbeat, can be a response to left-sided heart failure as the body attempts to compensate for the decreased cardiac output by increasing the heart rate to maintain adequate blood flow.
Choice F reason : Gastrointestinal bloating is more commonly associated with right-sided heart failure due to systemic venous congestion leading to fluid accumulation in the abdominal organs and tissues.
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