A nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?
Administer furosemide to the client.
Educate the client that oral fluids are not necessary.
Monitor the client's weight once a week.
Monitor the client's IV site and infusion.
The Correct Answer is D
A. Administering furosemide (a diuretic) would worsen dehydration and is contraindicated in this scenario. The goal is to rehydrate the client, not to promote fluid loss.
B. Educating the client that oral fluids are not necessary is incorrect. Oral fluids are important for rehydration, and the client should be encouraged to drink fluids unless contraindicated.
C. Monitoring the client's weight once a week is not sufficient for assessing dehydration status. More frequent monitoring is needed to assess the effectiveness of treatment.
D. Monitoring the client's IV site and infusion is essential to ensure that the IV is patent, the fluid is being infused properly, and there are no complications such as infiltration or infection. This is a key aspect of nursing care for clients receiving IV fluids.
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Related Questions
Correct Answer is D
Explanation
A. Withholding medication for phantom limb pain is inappropriate. Phantom limb pain is a real phenomenon, and it should be managed with appropriate analgesics or other pain management strategies.
B. Keeping the residual limb elevated immediately after surgery is not recommended for prolonged periods as it can lead to contractures. The goal is to avoid excessive flexion at the hip and promote proper positioning.
C. Continuing to use the limb prosthesis when skin is irritated could worsen the irritation and cause skin breakdown. Proper skin care and regular monitoring are essential before using the prosthesis.
D. Laying prone for 30 minutes, 3-4 times a day is an appropriate intervention to prevent hip contractures and encourage proper alignment of the residual limb. This helps to maintain the flexibility of the hip joint and prepares the client for prosthetic fitting.
Correct Answer is A
Explanation
A. Upper UTI refers to infections that affect the kidneys (pyelonephritis) and ureters. These infections are typically more serious and can lead to kidney damage if not treated promptly.
B. Lower UTI refers to infections that affect the bladder (cystitis) or urethra (urethritis), which are generally less severe than upper UTIs.
C. Urosepsis is a severe, systemic infection that results from a UTI that has spread to the bloodstream. It can occur with either upper or lower UTIs.
D. Uncomplicated UTI refers to a straightforward infection of the urinary tract, typically involving the bladder, in an otherwise healthy individual. It is not specifically related to the kidneys or ureters.
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