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: Mental alertness is not affected by the administration of hypertonic solutions. Hypertonic solutions are fluids that have a higher concentration of solutes than the blood. They draw water out of the cells and into the blood vessels, increasing the blood volume and osmolarity.

Choice B reason: Decreased pulse is not a result of administering hypertonic solutions too quickly. On the contrary, hypertonic solutions can increase the pulse rate as they increase the blood volume and pressure.

Choice C reason: Decreased blood pressure is not a consequence of administering hypertonic solutions too quickly. Hypertonic solutions can raise the blood pressure as they increase the blood volume and osmolarity.

Choice D reason: Fluid overload is the correct answer. Administering hypertonic solutions too quickly can cause fluid overload, which is a condition where the body has too much fluid in the blood vessels. This can lead to symptoms such as edema, dyspnea, crackles, and weight gain. Fluid overload can also cause heart failure, pulmonary edema, and cerebral edema.

A. The client quit smoking 6 months ago. B. The client has a strong family history of obesity. C. The client drinks six to eight cans of beer daily. D. The client has poorly controlled type 2 diabetes.

Correct Answer is C

Explanation

Choice A reason: The client quitting smoking 6 months ago is not a factor that would exclude her from being an appropriate surgical candidate. In fact, smoking cessation is a requirement for bariatric surgery, as smoking increases the risk of complications such as infection, thrombosis, and poor wound healing.

Choice B reason: The client having a strong family history of obesity is not a factor that would exclude her from being an appropriate surgical candidate. Family history is one of the genetic factors that can contribute to obesity, but it does not determine the eligibility for bariatric surgery. Other factors such as BMI, comorbidities, lifestyle, and motivation are more important.

Choice C reason: The client drinking six to eight cans of beer daily is a factor that would exclude her from being an appropriate surgical candidate. Alcohol abuse is a contraindication for bariatric surgery, as it can cause liver damage, malnutrition, dehydration, and addiction transfer. The client would need to abstain from alcohol for at least 6 months before and after the surgery.

Choice D reason: The client having poorly controlled type 2 diabetes is not a factor that would exclude her from being an appropriate surgical candidate. Type 2 diabetes is one of the comorbidities that can qualify a client for bariatric surgery, as it can improve or resolve after the surgery. However, the client would need to have a good glycemic control before the surgery to reduce the risk of complications.

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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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Explanation

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