Nokea
A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?
- A. Encourage increased fluid intake.
- B. Place the client in a high Fowler's position.
- C. Measure the client's intake and output.
- D. Restrict dietary sodium intake.
Correct Answer: D
Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.
You may also like to solve these questions
When planning care for a client with an indwelling urinary catheter, which nursing diagnosis has the highest priority?
- A. Self-care deficit
- B. Functional incontinence
- C. Fluid volume deficit
- D. High risk for infection
Correct Answer: D
Rationale: The highest priority nursing diagnosis when planning care for a client with an indwelling urinary catheter is 'High risk for infection.' Indwelling urinary catheters pose a significant risk of infection due to their direct contact with the urinary system. Preventing and managing infections is crucial in the care of these clients. Monitoring for signs of infection, following proper catheter care protocols, and maintaining aseptic technique during catheter maintenance are essential steps to prevent complications associated with catheter-related infections.
Choices A, B, and C are not the highest priority because in this case, the immediate concern is the risk of infection associated with the presence of the urinary catheter. While self-care deficit, functional incontinence, and fluid volume deficit are important considerations in overall patient care, they are not as critical as preventing potentially serious infections related to the indwelling urinary catheter.
What assessment finding places a client at risk for problems associated with impaired skin integrity?
- A. Scattered macules on the face
- B. Capillary refill of 5 seconds
- C. Smooth nail texture
- D. Presence of skin tenting
Correct Answer: B
Rationale: The correct answer is B. A capillary refill time greater than 3 seconds indicates poor perfusion, leading to impaired skin integrity. Delayed capillary refill can compromise blood flow to the skin, increasing the risk of pressure ulcers or wounds due to reduced tissue perfusion. Choices A, C, and D are incorrect because scattered macules on the face, smooth nail texture, and presence of skin tenting are not direct indicators of impaired skin integrity or risk for skin problems.
Prior to Mr. Landon undergoing a tracheostomy, what is the top nursing priority?
- A. Shaving the neck.
- B. Establishing a means of communication.
- C. Inserting a Foley catheter.
- D. Starting an IV.
Correct Answer: B
Rationale: Before Mr. Landon undergoes a tracheostomy, the top nursing priority is to establish a means of communication. This is essential to ensure that Mr. Landon can effectively communicate his needs during and after the procedure. Shaving the neck (Choice A) may be necessary for the tracheostomy but is not the top priority. Inserting a Foley catheter (Choice C) and starting an IV (Choice D) are important nursing interventions but are not the priority before a tracheostomy procedure, where communication is key for patient safety and comfort.
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?
- A. Aspirating gastric contents to assure a pH value of 4 or less.
- B. Hearing air pass in the stomach after injecting air into the tubing.
- C. Examining a chest x-ray obtained after the tubing was inserted.
- D. Checking the remaining length of tubing to ensure that the correct length was inserted.
Correct Answer: C
Rationale: The most accurate method to confirm the proper placement of a nasogastric tube is by examining a chest x-ray obtained after the tubing was inserted. This visual assessment allows healthcare providers to directly visualize the position of the tube in relation to anatomical landmarks, ensuring it is correctly placed in the stomach. Aspirating gastric contents or hearing air pass may provide some information but are not as definitive as a chest x-ray for confirming placement. Checking the remaining length of tubing is not a reliable method for determining proper placement as it does not indicate where the tip of the tube lies within the body.
Which serum laboratory value should the nurse monitor carefully for a client who has had an NG tube for suctioning for the past week?
- A. White blood cell count
- B. Albumin
- C. Calcium
- D. Sodium
Correct Answer: D
Rationale: The nurse should carefully monitor serum sodium levels for a client with an NG tube on suction for an extended period due to potential fluid loss and the risk of developing hyponatremia, an electrolyte imbalance. Hyponatremia can occur as a result of continual suctioning leading to fluid loss, making it crucial to monitor sodium levels to prevent complications associated with low sodium levels. Monitoring white blood cell count, albumin, or calcium is not directly related to the impact of NG tube suction on fluid and electrolyte balance, so these values are not the priority in this scenario.