Nokea
Which of the following nursing actions might be appropriate for a patient with fluid-volume excess?
- A. Administration of a diuretic ordered by the physician
- B. Encouraging consumption of a high-sodium diet ordered by the physician
- C. Auscultating the breath sounds every 4 hours
- D. Monitoring daily weights
- E. Assessing the SpO_2 every 4 hours, noting decreases
- F. Encouraging oral fluid intake of at least 1,800 mL / day
- G. Monitoring I/O (intake/output)
Correct Answer: A,C,D,E,G
Rationale: Appropriate actions include administering diuretics, monitoring breath sounds, weights, oxygen saturation, and intake/output to manage fluid overload.
You may also like to solve these questions
Your patient is taking a thiazide diuretic routinely and tends to run a low serum K? level even though the physician has prescribed K? supplementation and the patient reports taking it faithfully. Which of the following foods would you recommend the patient add to his diet to assist in maintaining normal K? levels?
- A. Baked potatoes
- B. Whole-grain bread
- C. Bananas
- D. Oranges
- E. Apricots
- F. Halibut
- G. Green beans
Correct Answer: A,C,D,E,F
Rationale: Potassium-rich foods like baked potatoes, bananas, oranges, apricots, and halibut help maintain normal potassium levels.
Your knowledge of which of the following pieces of data regarding potassium takes highest priority?
- A. Never give KCl IV push.
- B. Never administer potassium chloride by the direct intravenous route.
- C. $\mathrm{KCl}$ given IV push can cause fatal cardiac arrhythmias.
- D. Yes, this is a trick question. All of the above choices are essentially the same, but you probably will be able to remember to never give $\mathrm{KCl}$ direct IV push.
Correct Answer: D
Rationale: All statements emphasize the danger of administering potassium chloride IV push, which can cause fatal cardiac arrhythmias, making this knowledge critical.
ANF is another hormone that affects the body's water level. Which of the following statements regarding ANF are accurate?
- A. ANF's production is signaled when baroreceptors detect abnormally low pressure, meaning that blood volume is too low.
- B. ANF inhibits renin production by the kidneys.
- C. ANF causes sodium to be retained by the kidneys.
- D. The end result of ANF increases water loss through the kidneys.
Correct Answer: B,D
Rationale: Atrial natriuretic factor (ANF) inhibits renin production, promoting sodium and water excretion, which increases water loss through the kidneys.
Which of the following signs and symptoms may point toward a fluid-volume excess?
- A. Elevated blood pressure
- B. Clear lung fields
- C. Weight gain
- D. Edema of extremities
- E. Crackles in lungs
- F. Respiratory rate of 20 per minute
- G. Decrease in pulse volume
Correct Answer: A,C,D,E
Rationale: Signs of fluid-volume excess include elevated blood pressure, weight gain, edema, and crackles in lungs due to fluid accumulation.
Which of the following accurately describes the effects that ADH has in the body?
- A. It signals the kidneys to increase diuresis, pulling more water from the body to be excreted as urine.
- B. It suppresses urine production, thereby increasing the concentration of the urine.
- C. It directs the kidneys to increase water reabsorption.
- D. It regulates the body's water level independently of solutes.
Correct Answer: C
Rationale: Antidiuretic hormone (ADH) promotes water reabsorption in the kidneys, reducing urine output and concentrating the urine.