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 B
Explanation
This response acknowledges the patient's concerns and provides reassurance that the changes are temporary and will improve after surgery. Response is dismissive of the patient's concerns and may make the patient feel unheard. Response c may be helpful, but it does not address the patient's emotional concerns. Response d is not accurate because the patient has expressed feeling awful about their appearance.
Correct Answer is B
Explanation
Sudden discontinuation of prednisone can result in adrenal insufficiency and can lead to life-threatening complications. The nurse should also instruct the patient to report any symptoms of an infection, such as fever, to the doctor promptly, as prednisone can mask signs of an infection.
Monitoring for mood alterations and daily weight measurement are also important aspects of care, but they are not as crucial as the need to gradually taper off the medication.
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