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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Although increasing fluid intake and fiber intake are important interventions for preventing constipation, it is important to first assess the patient's current situation and risk factors for constipation. Additionally, while a daily bowel movement is not necessary for everyone, it is important to understand the patient's usual bowel habits and whether or not their current regimen is effective for them. Therefore, the nurse should perform a focused nursing assessment to identify the patient's risk factors for constipation and evaluate their current bowel regimen before providing specific interventions or recommendations.
Correct Answer is A
Explanation
Based on the given arterial blood gas results, the patient's pH is elevated, indicating alkalosis. The PaCO2 level is decreased, which suggests respiratory compensation. The bicarbonate (HCO3-) level is within the normal range. Therefore, the interpretation of the arterial blood gas results is respiratory alkalosis.
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