Electrolytes Question #4

Question

The nurse selects the problem of “fluid volume excess” for a client. Which intervention should be included in the plan of care?

Answers

  1. Change the IV fluid from 0.9% NS to Dextrose 5% and water..
    • Rationale:
  2. Restrict the amount of sodium in the client’s diet.
    • Rationale:
  3. Monitor blood glucose levels.
    • Rationale:
  4. Prepare the client for hemodialysis.
    • Rationale:

Overview

Explanation

The correct answer is B. Restricting the sodium in the client’s diet to be between 2 and 4 grams a day can help to reduce fluid retention. Sodium binds with water in the body to retain fluid both inside and outside the cells. A healthcare provider’s prescription is needed to change the type of IV fluid. There is no reason to monitor blood glucose levels. Hemodialysis is not indicated.

NCLEX TIP: Using critical thinking is recommended when reading priority questions. Recognizing key words in the answer choices will allow you to know how to choose the correct answer for the question. Go through each answer choice and decide is it: Maslow’s hierarchy, safety-related, or following the nursing process (ADPIE). Never complete a nursing action that is outside the scope of practice.

Learning Outcomes

Test Taking Tip

Video Rationale