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: Excessive stomach acid secretion is not the correct answer because it is not a diagnostic test, but a possible cause of peptic ulcer disease. Peptic ulcers are sores that develop in the lining of the stomach or duodenum due to damage from stomach acid and digestive enzymes.

Choice B reason: An incompetent pyloric sphincter is not the correct answer because it is not a diagnostic test, but a possible complication of peptic ulcer disease. The pyloric sphincter is a muscular valve that controls the passage of food from the stomach to the small intestine. If it becomes damaged or weakened, it can cause gastric outlet obstruction, which is a blockage of the stomach.

Choice C reason: A metabolic acid-base imbalance is not the correct answer because it is not a diagnostic test, but a possible consequence of peptic ulcer disease. Peptic ulcers can cause bleeding, perforation, or gastric outlet obstruction, which can affect the acid-base balance of the body. For example, vomiting can cause metabolic alkalosis, which is a condition where the blood is too alkaline.

Choice D reason: An infection with Helicobacter pylori is the correct answer. Helicobacter pylori is a type of bacteria that can infect the stomach and duodenum and cause inflammation and ulcers. It is the most common cause of peptic ulcer disease. The health care provider can order a diagnostic test to detect the presence of Helicobacter pylori in the client's stomach or blood, such as a urea breath test, a stool antigen test, or a blood antibody test.

A. These medications will coat the ulcer and decrease the acid production in my stomach. B. The medications will kill the bacteria and stop the acid production. C. I should take these medications only when I have pain from my ulcer. D. The medications will kill the bacteria and reduce the acid production.

Correct Answer is D

Explanation

Choice A reason: This is not a correct statement because these medications do not coat the ulcer. They are not antacids or mucosal protectants, which can form a protective layer over the ulcer and neutralize the stomach acid.

Choice B reason: This is not a correct statement because these medications do not stop the acid production. They only reduce it by inhibiting the proton pump, which is responsible for secreting acid into the stomach.

Choice C reason: This is not a correct statement because these medications should be taken as prescribed, not as needed. They are not analgesics or anti-inflammatory drugs, which can relieve the pain and inflammation of the ulcer.

Choice D reason: This is a correct statement because these medications have two effects: they kill the bacteria that cause the infection and inflammation of the ulcer, and they reduce the acid production that aggravates the ulcer. This can help heal the ulcer and prevent 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

A client presents to the clinic reporting vomiting and burning in her mid-epigastric area. The nurse knows that in the process of confirming peptic ulcer disease, the health care provider is likely to order a diagnostic test to detect the presence of what?

Correct Answer is D

Explanation

Correct Answer is D

Explanation

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