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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Furosemide is a loop diuretic that works by blocking the reabsorption of sodium and chloride in the ascending loop of Henle in the kidney, leading to increased urine output. However, this medication can also cause potassium loss through increased urinary excretion, which can lead to hypokalemia (low potassium level). Hypokalemia can cause confusion, weakness, and other neurological symptoms.
The normal range for serum potassium is 3.5 to 5.0 mEq/L. A potassium level of 2.9 mEq/L is below the normal range and is considered hypokalemic. Therefore, the nurse should correlate the client's confusion with the low potassium level and notify the healthcare provider to adjust the medication or provide potassium supplements if indicated.
Correct Answer is A
Explanation
NSAIDs are known to be a common cause of acute gastritis. Therefore, it is essential for the nurse to ask the patient about their frequency of NSAID use to determine if this may have caused their current symptoms. Other options such as family history of gastric problems, recent weight gain or loss, and amount of fat in the diet, may also be relevant to the patient's overall health status, but they are not as important as the potential cause of their current condition.
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