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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Related Questions
Correct Answer is A
Explanation
Excess fluid volume related to intake greater than output would be the most appropriate nursing diagnosis for a patient with symptoms of DI (diabetes insipidus). This condition results in excessive urine output and, as a consequence, can lead to dehydration and electrolyte imbalances. Therefore, monitoring and managing fluid volume is a priority for patients with DI.
Risk for impaired skin integrity related to generalized edema is more commonly associated with conditions that cause fluid retention such as heart failure, liver failure, or kidney disease, rather than DI.
Activity intolerance related to muscle cramps and weakness is a possible nursing diagnosis for patients with conditions that affect muscle function, such as muscular dystrophy or multiple sclerosis, but not specifically for DI.
Insomnia related to waking at night to void is more commonly associated with urinary frequency or nocturia due to conditions such as urinary tract infections or benign prostatic hyperplasia, but not specifically for DI.
Correct Answer is C
Explanation
Type 2 diabetes mellitus is a metabolic disorder characterized by high blood sugar levels resulting from decreased insulin secretion and/or increased insulin resistance. In type 2 diabetes, the body's cells become resistant to insulin, which is a hormone that helps regulate blood sugar levels by allowing glucose to enter cells for energy. As a result, the pancreas produces more insulin to compensate for the increased demand, but over time, the pancreas may not be able to keep up, and blood sugar levels rise.
Unlike type 1 diabetes, which is an autoimmune disorder in which the body's immune system destroys the insulin-producing cells in the pancreas, people with type 2 diabetes still produce insulin, but their body is not able to use it effectively. Therefore, type 2 diabetes can be managed through lifestyle changes, such as diet and exercise, and/or medication, such as oral hypoglycemic agents or insulin therapy.
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