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

Based on the given documentation, the nurse suspects that the client has respiratory alkalosis. The client's ABG results show a pH of 7.52, which indicates alkalosis and the PaO2 level is slightly low, suggesting respiratory involvement. Rapid breathing (RR44) and wheezing also support the possibility of respiratory alkalosis.

A. I should weigh myself daily and report any sudden weight loss or gain." B. I need to limit my ﬂuid intake to no more than 1 quart of liquids a day," C. I will eat foods high in potassium because the diuretics cause potassium loss.” D. I need to shop for foods that are low in sodium and avoid adding salt to foods.

Correct Answer is C

Explanation

The correct answer is c. I will eat foods high in potassium because the diuretics cause potassium loss.

Rationale for Choice A:

Statement:"I should weigh myself daily and report any sudden weight loss or gain."
Rationale:This statement is correct.It's crucial for patients with SIADH to monitor their weight daily as even slight fluctuations can signal fluid imbalances.Sudden weight gain can indicate fluid retention,while sudden weight loss might suggest dehydration.Both scenarios warrant medical attention.

Rationale for Choice B:

Statement:"I need to limit my fluid intake to no more than 1 quart of liquids a day."
Rationale:This statement is also correct.Fluid restriction is a cornerstone of SIADH management.By limiting fluid intake,patients can help prevent the buildup of excess fluid in the body,which can lead to complications such as hyponatremia (low sodium levels in the blood) and edema.

Rationale for Choice C:

Statement:"I will eat foods high in potassium because the diuretics cause potassium loss."
Rationale:This statement is incorrect.While some diuretics used in the treatment of SIADH can indeed cause potassium loss,this is not a universal side effect.Furthermore,increasing potassium intake without medical supervision can be dangerous,potentially leading to hyperkalemia (high potassium levels in the blood).It's essential for patients to consult with their healthcare providers for individualized guidance on potassium intake.

Rationale for Choice D:

Statement:"I need to shop for foods that are low in sodium and avoid adding salt to foods."
Rationale:This statement is correct.A low-sodium diet is often recommended for patients with SIADH to help manage fluid balance and prevent hyponatremia.Restricting sodium intake can reduce fluid retention and help maintain appropriate sodium levels in the blood.

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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?

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Naxlex Comprehensive Predictor Exams

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