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A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first?*1 pointa. Has had diabetes mellitus for 12 yearsb. Uses sodium-containing antacids frequentlyc. Just received 3 units of packed red blood cellsd. Had abdominal surgery and has a nasogastric tube

Question

A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first?*1 pointa. Has had diabetes mellitus for 12 yearsb. Uses sodium-containing antacids frequentlyc. Just received 3 units of packed red blood cellsd. Had abdominal surgery and has a nasogastric tube

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Solution

The nurse should first assess the client who "Just received 3 units of packed red blood cells". This is because the administration of blood products can lead to fluid overload, especially in clients who may already have compromised cardiac function. This can result in overhydration, which can be a serious condition.

The other options are less immediate risks for overhydration. Diabetes mellitus can lead to dehydration if not properly managed, sodium-containing antacids can lead to fluid retention but not necessarily overhydration, and a nasogastric tube post abdominal surgery is typically used to decompress the stomach, not hydrate the patient.

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