A nurse is caring for several patients with fluid imbalances. A priority nursing intervention for a client with hypervolemia involves which of the following?

Monitoring respiratory status for signs and symptoms of pulmonary complications

Encouraging the client to consume sodium-free fluids

Weighing dressings with a large-bore catheter

Drawing a blood sample for typing and cross-matching

Answer and Explanation

The Correct Answer is A

Choice A reason: Monitoring respiratory status for signs and symptoms of pulmonary complications is a priority nursing intervention for a client with hypervolemia. Hypervolemia is a condition where there is excess fluid in the blood vessels, which can cause fluid to leak into the lungs and impair gas exchange. The nurse should assess the client for signs of pulmonary edema, such as dyspnea, crackles, cough, and pink-tinged sputum.

Choice B reason: Encouraging the client to consume sodium-free fluids is not a priority nursing intervention for a client with hypervolemia. Sodium-free fluids may still contribute to fluid overload, especially if the client has impaired renal function or heart failure. The nurse should limit the client's fluid intake and administer diuretics as prescribed to reduce the fluid volume.

Choice C reason: Weighing dressings with a large-bore catheter is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client with hemorrhage, who may lose blood through a large-bore catheter or dressing. The nurse should monitor the client's blood pressure, pulse, and hemoglobin levels for signs of blood loss.

Choice D reason: Drawing a blood sample for typing and cross-matching is not a priority nursing intervention for a client with hypervolemia. This may be a relevant intervention for a client who needs a blood transfusion, which may be indicated for a client with anemia, trauma, or surgery. The nurse should check the client's blood type and compatibility before administering any blood products.

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Correct Answer is D

Explanation

Choice A reason: This is not a correct answer because 0.9% Sodium Chloride is an isotonic solution, which means it has the same osmolarity as the blood plasma. It does not cause any fluid shifts between the intracellular and extracellular compartments.

Choice B reason: This is not a correct answer because Lactated Ringer's is an isotonic solution, which means it has the same osmolarity as the blood plasma. It does not cause any fluid shifts between the intracellular and extracellular compartments.

Choice C reason: This is not a correct answer because D5W (5% Dextrose in Water) is an isotonic solution when it is in the IV bag, but it becomes hypotonic once it enters the body, as the dextrose is rapidly metabolized and only water remains. However, it is not a preferred solution for a patient with critically high sodium, as it can cause cerebral edema and worsen the neurological status.

Choice D reason: This is a correct answer because 0.45% Sodium Chloride is a hypotonic solution, which means it has a lower osmolarity than the blood plasma. It causes fluid to shift from the extracellular to the intracellular compartment, which can help lower the sodium level and correct the fluid imbalance.

A. Include foods high in starch and proteins B. Include foods high in fiber C. Avoid foods high in sodium D. Avoid foods high in fat

Correct Answer is D

Explanation

Choice A reason: Including foods high in starch and proteins is not a specific dietary instruction for a client who has biliary colic from chronic cholecystitis. Starch and protein intake may vary depending on the client's overall nutritional needs and preferences.

Choice B reason: Including foods high in fiber is a general dietary recommendation for most people, but it is not directly related to biliary colic or cholecystitis. Fiber helps with bowel regularity and may lower the risk of some chronic diseases, but it does not affect the production or flow of bile.

Choice C reason: Avoiding foods high in sodium is a dietary instruction for clients who have hypertension, heart failure, or kidney disease, but it is not relevant for biliary colic or cholecystitis. Sodium intake does not influence the formation or dissolution of gallstones, which are the main cause of biliary colic.

Choice D reason: Avoiding foods high in fat is a dietary instruction for clients who have biliary colic from chronic cholecystitis. Fat intake stimulates the contraction of the gallbladder, which can cause pain and inflammation if there are gallstones blocking the bile ducts. Reducing fat intake can help prevent or reduce the frequency and severity of biliary colic episodes.

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A nurse is caring for several patients with fluid imbalances. A priority nursing intervention for a client with hypervolemia involves which of the following?

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