Medical Surgical Sodium Na+ #9

Question

The nurse plans care for a client with fluid volume excess and hyponatremia. Which intervention will the nurse include in the plan of care?

Answers

  1. Limit fluids to 1000 mL/day
    • Rationale:

      This answer is correct because the client who is experiencing hypervolemia will require restriction of oral fluid intake as a method of allowing the client’s body to compensate and remove some of the excess fluid volume.

  2. Administer NS at keep open rate
    • Rationale:

      This answer is not correct because infusions of fluids, even just to keep the vein open, will increase the fluid volume excess. Fluids need to be restricted.

  3. Administer furosemide 80 mg slow IVP
    • Rationale:

      This answer is not correct because diuretics, including furosemide, will cause a further decline in sodium levels. 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.

  4. Administer NS intravenous solution at 125 mL/hr continuously
    • Rationale:

      This answer is not correct because infusions of fluids will increase the fluid volume excess. Fluids need to be restricted.

Overview

Fluid volume excess (i.e., hypervolemia) refers to an isotonic expansion of the extracellular fluid (ECF) due to an increase in total body sodium content and an increase in total body water.

Explanation

Learning Outcomes

Clinical manifestations associated with fluid volume excess include dyspnea, edema, hypertension, and rapid weight gain. This condition is often the result of cirrhosis and kidney or heart failure. 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.

Test Taking Tip

Consider the pathophysiology of fluid volume excess to answer this question correctly.

Video Rationale