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 C

Explanation

Clostridium difficile is a highly contagious bacteria that can spread easily from person to person. The patient should be placed in a private room to prevent the spread of the infection to other patients. Contact isolation precautions should also be implemented, which involves wearing gloves and a gown when entering the patient's room, as well as washing hands thoroughly after leaving the room.

Options a and b are not directly related to the care of a patient with Clostridium difficile. Option d is also not directly related, although proper food handling and storage can help prevent the spread of other types of infections.

A. encourage the patient to drink at least 3000 ml of ﬂuid a day. B. suggest that the patient increase dietary intake of foods that are high in fiber. C. inform the patient that a daily bowel movement is not necessary. D. perform a focused nursing assessment to identify risk factors for constipation.

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.

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