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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is not a correct result that the nurse should anticipate. RBC stands for red blood cells, which carry oxygen and carbon dioxide in the blood. The normal range for RBC is 4-5.5 /mm^3^, so a value of 4.2 /mm^3^ is within the normal range and does not indicate any abnormality.
Choice B reason: This is a correct result that the nurse should anticipate. WBC stands for white blood cells, which fight infections and inflammation in the body. The normal range for WBC is 5-10 /mm^3^, so a value of 17 /mm^3^ is above the normal range and indicates leukocytosis, which is an increase in the number of white blood cells. Leukocytosis can be caused by acute appendicitis, as the body tries to fight the infection and inflammation in the appendix.
Choice C reason: This is not a correct result that the nurse should anticipate. Neutrophils are a type of white blood cell that are the first to respond to bacterial infections. The normal range for neutrophils is 3-5.8 /mm^3^, so a value of 3.2 /mm^3^ is within the normal range and does not indicate any abnormality.
Choice D reason: This is not a correct result that the nurse should anticipate. Lymphocytes are a type of white blood cell that are involved in the immune response and the production of antibodies. The normal range for lymphocytes is 1-4 /mm^3^, so a value of 3 /mm^3^ is within the normal range and does not indicate any abnormality.
Correct Answer is C
Explanation
Choice A reason: An obese client whose parents and siblings are not obese may have obesity due to environmental or behavioral factors, such as diet, physical activity, or stress. Medication may not be effective for this type of obesity, and lifestyle changes may be more appropriate.
Choice B reason: A client with long-standing obesity who has recently been diagnosed with type 2 diabetes may have obesity due to insulin resistance, which impairs the body's ability to use glucose and increases fat storage. Medication may help with glucose control, but it may not resolve the obesity. The client may also need to follow a diabetic diet and exercise regimen.
Choice C reason: A client whose obesity has been attributed to a reversible endocrine disorder like hypothyroidism may have obesity due to hormonal imbalance, which affects the metabolism and energy expenditure. Medication may be effective for this type of obesity, as it can restore the normal function of the thyroid gland and increase the metabolic rate.
Choice D reason: A client whose obesity is characterized as android rather than gynoid may have obesity due to genetic or gender factors, such as the distribution of fat in the upper body or the influence of male hormones. Medication may not be effective for this type of obesity, and the client may benefit from other interventions such as surgery or counseling.
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