Electrolytes Question #57

Question

The nurse is planning care for a client with fluid volume excess and hyponatremia. Which intervention will the nurse include?

Answers

  1. Administer NS at keep open rate
    • Rationale:
  2. Limit fluids to 1000 mL/day
    • Rationale:
  3. Administer NS intravenous solution at 125 mL/hr continuously
    • Rationale:
  4. Administer furosemide 80 mg slow IVP
    • Rationale:

Overview

Explanation

The correct answer is B. By limiting fluid intake to 1000 mL/day the client’s body will be given a chance to remove some of the excess fluid volume. Due to the hyponatremia, sodium level should not be lowered and an increased sodium intake could cause an even greater fluid volume excess. Infusions of fluids will increase the fluid volume excess. Diuretics will cause a further decline in sodium levels.

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