92. A client with CHF has: 2+ pedal edema, jugular venous distention (JVD), bilateral basilar crackles, urine output of 1.2 L/24 hr, blood pressure of 145/88 mm Hg, Na+ of 129. A nurse should plan to:
92. A client with CHF has: 2+ pedal edema, jugular venous distention (JVD), bilateral basilar crackles, urine output of 1.2 L/24 hr, blood pressure of 145/88 mm Hg, Na+ of 129. A nurse should plan to:
Test-Taking Tip
Interpret the data. Recognize the signs of fluid excess. Three of the options add sodium; only one limits fluid.
Content Area: Adult Health, Fluid and Electrolyte Imbalances; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Fluid and Electrolyte Imbalances
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Answer 1 is correct because generally low serum sodium results from excessive water intake or retention. This client has adequate fluid levels. Fluid restriction will help treat the hyponatremia. Answer 2 is incorrect because generally low serum sodium results from excessive water intake or retention. It is correctly treated with water restriction. Answer 3 is incorrect because this client does not need fluids. Answer 4 is incorrect because generally low serum sodium results indicate excessive water intake or retention. It is correctly treated with water restriction, not fluids by IV.
