Choice A reason:

Decreased hematocrit is not a finding of dehydration, but rather of overhydration or hemodilution. Hematocrit is the percentage of red blood cells in the blood volume. When the blood volume is reduced due to dehydration, the hematocrit increases, not decreases.

Choice B reason:

Increased urine specific gravity is a finding of dehydration, as it indicates that the urine is more concentrated due to less water in the body. Urine specific gravity is a measure of the density of urine compared to water. Normal urine specific gravity ranges from 1.005 to 1.030. When the body is dehydrated, the kidneys reabsorb more water and produce less urine, resulting in higher urine specific gravity.

Choice C reason:

Decreased serum sodium is not a finding of dehydration, but rather of hyponatremia or low sodium level in the blood. Serum sodium is the amount of sodium in the blood plasma. Normal serum sodium ranges from 135 to 145 mEq/L. When the body is dehydrated, the serum sodium increases, not decreases, because there is less water to dilute the sodium concentration.

Choice D reason:

Increased capillary refill time is a finding of dehydration, as it indicates that the blood flow to the peripheral tissues is impaired due to low blood volume. Capillary refill time is the time it takes for the color to return to the nail bed after applying pressure. Normal capillary refill time is less than 3 seconds. When the body is dehydrated, the blood pressure drops and the heart rate increases to maintain adequate perfusion to vital organs, resulting in longer capillary refill time.

Choice A reason:

Monitoring intake and output is an important intervention for a client who has overhydration because it helps to assess the fluid balance and the effectiveness of treatment. The nurse should measure and record all sources of fluid intake and output, including oral, intravenous, tube feeding, urine, stool, wound drainage, and other losses.

Choice B reason:

Restricting fluid intake as prescribed is another intervention for a client who has overhydration because it helps to reduce the excess fluid volume and prevent further complications. The nurse should follow the prescribed fluid restriction and educate the client and family about the rationale and guidelines for fluid restriction.

Choice C reason:

Administering diuretics as prescribed is a pharmacological intervention for a client who has overhydration because it helps to increase urine output and eliminate excess fluid and sodium from the body. The nurse should monitor the client's response to diuretics, such as urine output, weight, blood pressure, electrolytes, and kidney function.

Choice D reason:

Elevating the head of the bed is a comfort measure for a client who has overhydration because it helps to improve breathing and reduce pulmonary congestion caused by fluid accumulation in the lungs. The nurse should elevate the head of the bed to at least 30 degrees or more, depending on the client's tolerance and preference.

Choice E reason:

Encouraging ambulation is not an appropriate intervention for a client who has overhydration because it may worsen the fluid overload and increase the risk of complications such as heart failure, pulmonary edema, or cerebral edema. The nurse should limit the client's physical activity and provide rest periods to conserve energy and reduce oxygen demand.

Choice A reason:

Limiting salt intake to 2 grams per day is a good dietary modification for a client who has fluid volume overload, but it is not the best answer. Salt (sodium) can cause the body to retain water and increase the fluid volume in the bloodstream and tissues. Reducing salt intake can help prevent or reduce fluid overload, but it may not be enough by itself.

Choice B reason:

Drinking at least 3 liters of water every day is a bad dietary modification for a client who has fluid volume overload. This would increase the fluid intake and worsen the condition. A client who has fluid volume overload should limit their fluid intake to avoid excess fluid accumulation in the body. The amount of fluid restriction depends on the severity of the condition and the client's weight, urine output, and other factors.

Choice C reason:

Avoiding foods that are high in potassium is a bad dietary modification for a client who has fluid volume overload. Potassium is an essential mineral that helps regulate the balance of fluids and electrolytes in the body. A client who has fluid volume overload may have low potassium levels due to diuretic therapy, kidney problems, or other causes. Low potassium levels can cause muscle weakness, irregular heartbeat, and other complications. A client who has fluid volume overload should eat foods that are high in potassium, such as bananas, potatoes, tomatoes, oranges, and spinach, unless they have a medical condition that requires potassium restriction.

Choice D reason:

Using herbs and spices instead of salt to season food is the best dietary modification for a client who has fluid volume overload. This would help reduce the sodium intake and prevent or decrease fluid retention in the body. Herbs and spices can also add flavor and variety to the diet without adding calories or fat. Some examples of herbs and spices that can be used instead of salt are garlic, onion, ginger, basil, oregano, rosemary, thyme, parsley, cilantro, mint, lemon, lime, vinegar, pepper, chili, cumin, curry, turmeric, paprika, cinnamon, nutmeg, and cloves.

Choice A reason: Slow down the infusion rate. This is the correct answer because the client is showing signs of fluid volume overload, which can result from rapid or excessive infusion of IV fluids. Slowing down the infusion rate can help prevent further fluid accumulation in the lungs and reduce the risk of pulmonary edema, which can impair gas exchange and cause respiratory distress.

Choice B reason:

Check the client's weight. This is not the correct answer because checking the client's weight is not a priority action in this situation. Although weight changes can reflect fluid balance, they are not an immediate indicator of fluid overload or deficit. The nurse should check the client's weight daily at the same time, but not before addressing the acute respiratory symptoms.

Choice C reason:

Notify the provider. This is not the correct answer because notifying the provider is not the first action that the nurse should take. The nurse should first implement independent nursing interventions to stabilize the client's condition, such as slowing down the infusion rate, elevating the head of the bed, and administering oxygen as needed. The nurse should notify the provider after assessing the client and intervening appropriately.

Choice D reason:

Raise the client's legs. This is not the correct answer because raising the client's legs can worsen fluid overload by increasing venous return to the heart and lungs. The nurse should avoid this position for clients who have crackles in the lungs, dyspnea, and increased blood pressure, as these are signs of fluid volume excess.

• Choice A reason:

• Serum osmolality 280 mOsm/kg is not a sign of overhydration. Serum osmolality measures the concentration of dissolved particles in the blood. Normal serum osmolality ranges from 275 to 295 mOsm/kg. Overhydration causes serum osmolality to decrease because of the excess water in the blood.

• Choice B reason:

• Serum sodium 150 mEq/L is not a sign of overhydration. Serum sodium measures the amount of sodium (salt) in the blood. Normal serum sodium ranges from 135 to 145 mEq/L. Overhydration causes serum sodium to decrease because of the dilution of sodium by excess water. This condition is called hyponatremia and can affect brain function.

• Choice C reason:

• Hemoglobin 18 g/dL is not a sign of overhydration. Hemoglobin is a protein in red blood cells that carries oxygen. Normal hemoglobin ranges from 12 to 16 g/dL for women and from 14 to 18 g/dL for men. Overhydration does not directly affect hemoglobin levels, but it can cause hemodilution, which is a decrease in the concentration of hemoglobin due to increased plasma volume.

• Choice D reason:

• Urine specific gravity 1.005 is a sign of overhydration. Urine specific gravity measures the concentration of urine compared to water. Normal urine specific gravity ranges from 1.010 to 1.030. Overhydration causes urine specific gravity to decrease because of the excess water in the urine. This indicates that the kidneys are excreting more water than solutes.