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 the best response because it does not accurately describe the client's condition. Obstruction is a possible complication of diverticulitis, but it is not indicated by fever and abdominal rigidity. Obstruction is more likely to cause symptoms such as nausea, vomiting, constipation, and abdominal distension.

Choice B reason: This is not the best response because it can worsen the client's condition. Positioning the client supine and inserting an NG tube are interventions for gastric outlet obstruction, not diverticulitis. An NG tube can increase the risk of infection and perforation in the inflamed colon. Supine position can also increase the pressure on the abdomen and cause more pain and discomfort.

Choice C reason: This is not the best response because it can be harmful to the client. Administering a fleet enema is contraindicated for diverticulitis, as it can cause more inflammation, bleeding, or perforation in the colon. A fleet enema is a type of laxative that contains sodium phosphate and is used to relieve constipation or prepare for colonoscopy.

Choice D reason: This is the best response because it is the most appropriate and urgent action for the client. Contacting the primary provider promptly and reporting these signs of perforation is essential for the client's safety and treatment. Perforation is a life-threatening complication of diverticulitis, where the colon wall ruptures and causes peritonitis, which is inflammation of the abdominal cavity. Perforation can cause symptoms such as fever, abdominal rigidity, tenderness, and rebound pain. Perforation requires immediate surgical intervention and antibiotic therapy.

A. An obese client whose parents and siblings are not obese B. A client with long-standing obesity who has recently been diagnosed with type 2 diabetes C. A client whose obesity has been attributed to a reversible endocrine disorder like hypothyroidism D. A client whose obesity is characterized as android rather than gynoid

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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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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