A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid replacement. Which of the following interventions should the nurse contribute to the plan of care?

Check for neck vein distention.

Offer oral fluids every 4 hr.

Monitor pulse pressure every 6 hr.

Limit oral fluids prior to bedtime.

Answer and Explanation

The Correct Answer is A

Answer is a. Check for neck vein distention.

a. Check for neck vein distention: Correct. Assessing for neck vein distention is an essential intervention for a client receiving IV fluid replacement, especially for dehydration. Neck vein distention can indicate fluid overload, a potential complication of IV fluid therapy. By monitoring for this sign, the nurse can promptly recognize and intervene to prevent fluid overload-related complications such as pulmonary edema and hypertension. Regular assessment of neck vein distention provides valuable information about the client's fluid status and guides adjustments to the IV fluid infusion rate to maintain fluid balance and prevent adverse outcomes.

b. Offer oral fluids every 4 hr: This option is incorrect because offering oral fluids every 4 hours may not be appropriate for a client receiving IV fluid replacement for dehydration. IV fluid replacement is typically indicated when oral rehydration is insufficient or impractical, such as in cases of severe dehydration, altered consciousness, or gastrointestinal disturbances. The frequency and volume of oral fluid intake should be individualized based on the client's condition, fluid requirements, and ability to tolerate oral intake. Therefore, the nurse should prioritize IV fluid therapy and adjust oral fluid intake accordingly based on ongoing assessment of the client's hydration status.

c. Monitor pulse pressure every 6 hr: While monitoring pulse pressure can provide valuable information about fluid status and cardiac function, it may not be as specific or sensitive as other signs such as neck vein distention when assessing for fluid overload in clients receiving IV fluid replacement. Pulse pressure is the difference between the systolic and diastolic blood pressure readings and can be affected by various factors, including cardiac output, vascular resistance, and volume status. However, changes in pulse pressure may not always correlate directly with fluid overload, especially in clients with underlying cardiovascular conditions or receiving vasopressor medications. Therefore, more frequent and comprehensive assessments, including physical examination findings such as neck vein distention, are necessary to evaluate fluid balance accurately.

d. Limit oral fluids prior to bedtime: This option is incorrect because limiting oral fluids prior to bedtime is generally not indicated for dehydrated clients, especially those receiving IV fluid replacement. Restricting fluid intake may exacerbate dehydration and compromise the effectiveness of IV fluid therapy. Instead, the nurse should encourage adequate fluid intake throughout the day and evening to promote hydration and support the client's recovery from dehydration. Individualized fluid management strategies should be based on the client's fluid requirements, renal function, underlying condition, and response to therapy.

In summary, the correct answer is a because checking for neck vein distention is an essential intervention for monitoring fluid status and detecting potential complications such as fluid overload in clients receiving IV fluid replacement for dehydration. This assessment helps ensure safe and effective fluid management and prevents adverse outcomes associated with fluid overload.

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Correct Answer is A

Explanation

Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux.

Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea.

Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site.

Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.

The explanation for why the other choices are not answered: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.

A. "I will perform breast exams every other month." B. "It is common for the skin on my breasts to dimple." C. "It is common for one breast to be larger than the other." D. "I will perform breast exams the day my period begins."

Correct Answer is C

Explanation

Choice A rationale: Breast self-examinations should be performed monthly, not every other month. This regularity helps with early detection of any changes.

Choice B rationale: Dimpling of the skin on the breasts is not common and can be a sign of breast cancer or other conditions. This statement indicates a misunderstanding.

Choice C rationale: It is indeed common for one breast to be slightly larger than the other. This is a normal variation and not usually a cause for concern.

Choice D rationale: Breast self-examinations should be performed several days after the menstrual period ends, not the day the period begins. This timing helps to reduce the likelihood of hormonal changes affecting breast tissue.

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A nurse is assisting in the plan of care for a client who is dehydrated and is receiving IV fluid replacement. Which of the following interventions should the nurse contribute to the plan of care?

Nursing Test Bank

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Correct Answer is C

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