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

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.

A. The patient has a urine output of 800 ml/hr. B. The patient is confused and lethargic. C. The patient's urine specific gravity is 1.003. D. The patient had a recent head injury.

Correct Answer is B

Explanation

Diabetes insipidus is a condition where the body is not able to regulate water balance properly, leading to excessive urine output and dehydration. The patient's urine output of 800 ml/hr (option A) and low urine specific gravity of 1.003 (option C) is consistent with diabetes insipidus and requires monitoring, but they are not as immediately concerning as the patient's confusion and lethargy.

Confusion and lethargy may indicate severe dehydration, electrolyte imbalances, or even brain swelling (if the patient had a recent head injury, as mentioned in option D). These symptoms require immediate attention to prevent further complications and ensure the patient's safety.

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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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