The nurse is caring for a patient with hypothermia and ﬂuid volume excess. Which of the following would be included in the plan of care?

Fluid restriction

Administration of hypotonic IV ﬂuids

Placement of an indwelling urinary catheter

Administration Of action-exchange resin

Answer and Explanation

The Correct Answer is A

The plan of care for a patient with hypothermia and ﬂuid volume excess would typically include measures to increase the patient's body temperature and decrease their ﬂuid volume. Therefore, option a (ﬂuid restriction) would be appropriate for this patient.

Options b (administration of hypotonic IV ﬂuids) and d (administration of ion-exchange resin) would not be appropriate because they would increase the patient's ﬂuid volume rather than decrease it.

Option c (placement of an indwelling urinary catheter) may be appropriate to closely monitor the patient's urine output, which is an important indicator of their ﬂuid status. However, this alone would not be sufficient to manage the patient's hypothermia and ﬂuid volume excess.

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Correct Answer is B

Explanation

The statement "I had the stomach ﬂu earlier this week and couldn't take the hydrocortisone" indicates that the patient may not be adhering to their prescribed medication regimen, which can lead to an Addisonian crisis. Therefore, the nursing diagnosis of ineﬀective therapeutic regimen management related to lack of knowledge of management of the condition is appropriate.

Addison’s disease is a condition in which the adrenal glands do not produce enough cortisol and aldosterone. Hydrocortisone is a glucocorticoid medication that is often used to replace the cortisol that the adrenal glands are not producing. In the Addisonian crisis, the body is unable to produce the necessary levels of cortisol and aldosterone, which can lead to potentially life-threatening complications such as hypotension, dehydration, and electrolyte imbalances.

The other statements may indicate areas where patient education is needed, but they do not directly relate to the immediate risk of an Addisonian crisis.

A. Withhold the medication. B. Administer a hypertonic solution. C. Repeat the potassium level. D. Monitor for paresthesia.

Correct Answer is C

Explanation

Before administering any medication, the nurse should confirm the potassium level to ensure that it is still elevated and needs to be treated. Potassium levels can ﬂuctuate, so repeating the test will ensure that the client receives the appropriate treatment.

Options (a) Withhold the medication and (b) Administering a hypertonic solution may be appropriate interventions depending on the client's condition, but confirming the potassium level is the first step.

Option (d) Monitoring for paresthesia is important but not the first action that the nurse should take.

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The nurse is caring for a patient with hypothermia and ﬂuid volume excess. Which of the following would be included in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is admitted to the hospital in Addisonian Crisis a month after a diagnosis of Addison’s disease. The nurse identifies the nursing diagnosis of ineﬀective therapeutic regimen management related to lack of knowledge of management of the condition when the patient says:

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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