Factors Affecting Body Fluid, Electrolyte Fluid Imbalances
Factors Affecting Body Fluid, Electrolyte Fluid Imbalances ( 5 Questions)
A nurse is caring for a client who has overhydration. Which of the following interventions should the nurse implement? (Select all that apply.)
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.
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.
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.
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.
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:
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.