Which action would the nurse take with the client experiencing rising blood osmolality and orthostatic hypotension?
A Restrict fluid intake.
B Auscultate the abdomen.
C Review the intake and output.
D Order an ultrasound of the
The correct answer and explanation is:
The correct answer is C: Review the intake and output.
In a client experiencing rising blood osmolality and orthostatic hypotension, it is essential to assess their fluid balance. Rising blood osmolality suggests that the client may be dehydrated, with increased concentration of solutes in the blood, which could contribute to orthostatic hypotension. When blood osmolality increases, the body may attempt to conserve water through mechanisms such as the release of antidiuretic hormone (ADH), but if dehydration persists, the client may experience symptoms like dizziness or fainting upon standing due to insufficient blood volume to maintain proper circulation.
Reviewing the client’s intake and output (I&O) helps determine if the client is consuming enough fluids and if they are losing excessive fluids through urine, vomiting, diarrhea, or sweating. A decrease in fluid intake or an increase in fluid loss could explain both the rising osmolality and orthostatic hypotension. By assessing I&O, the nurse can identify the cause and intervene by recommending fluid replacement if necessary.
In contrast, the other options are less directly related to managing rising blood osmolality and orthostatic hypotension:
- A Restricting fluid intake would worsen dehydration and potentially exacerbate both the rising osmolality and the orthostatic hypotension.
- B Auscultating the abdomen is typically done to assess bowel sounds or abdominal issues, which are not the primary concerns with rising osmolality or orthostatic hypotension.
- D Ordering an ultrasound might be useful if there is suspicion of an underlying structural issue, but it would not immediately address the fluid imbalance causing the symptoms.
By focusing on reviewing intake and output, the nurse can better understand the client’s fluid status and guide appropriate interventions to restore balance and improve the symptoms of orthostatic hypotension.