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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. DSW (Dextrose in water) is not specifically used for compatibility with antibiotics. It is an intravenous fluid that provides water and glucose, but its use is not based on antibiotic compatibility.
B. DSW (5% dextrose in water) provides free water to the body. In the case of acute dehydration and hypernatremia, the water helps to dilute the high sodium levels in the bloodstream, lowering the sodium concentration.
C. DSW does not contain higher-than-normal amounts of sodium. It contains only a small amount of sodium from the dextrose, and its primary role is to provide free water.
D. DSW is not used to pull water out of the interstitial space. Hypertonic solutions (like 3% saline) are used for that purpose, not DSW.

A. The pain comes from severed blood vessels in the residual stump. B. It is psychosomatic pain that the patient is just imagining. C. It is often treated with adjunct medications such as antiepileptics and antidepressants. D. It is somatic pain that always responds well to opioid medications.

Correct Answer is C

Explanation

A. The pain does not come from severed blood vessels in the residual stump. Phantom limb pain is not caused by the stump itself but rather by the brain’s perception of the missing limb.
B. Phantom limb pain is not psychosomatic. It is a real phenomenon where the brain continues to receive signals from nerves that were previously connected to the amputated limb.
C. Phantom limb pain is often treated with adjunct medications such as antiepileptics (e.g., gabapentin) and antidepressants (e.g., amitriptyline), which help modify the way the brain processes pain signals.
D. While opioid medications can be used for pain management, phantom limb pain often does not respond well to opioids. It typically requires a combination of other treatments, such as those mentioned in C.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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