A 74-year-old female older adult was admitted to the ER with Shortness of breath, lethargy, and dry oral mucosa. The patient reports being thirsty, and no complaints of pain are noted. BP is 90/50, HR 122, temperature 100, and pulse ox is 94%. The patient is started on IV therapy and has been diagnosed with Dehydration. Her height is 5 Feet, 3 inches and her current weight is 98 pounds. Dark scanty urine present, NKDA or NKFA and has a history of gout, falls, and loss of appetite.
After reviewing the patient's information, identify all pertinent assessment data that is important and of immediate concern.
Select all that apply.
Weight 98Lbs
Dehydrated
Admitted to the ER
Lethargy
HR 122
Shortness of Breath
Temperature 100
Thirsty
Female
BP 90/50
Correct Answer : A,B,D,E,F,G,H,J
● Weight 98 lbs: This information helps determine the patient's baseline weight and assess for potential weight loss associated with dehydration.
● Dehydrated: The diagnosis of dehydration indicates a critical condition that requires immediate attention and intervention.
● Lethargy: Lethargy suggests a decreased level of consciousness and could indicate a severe state of dehydration or other underlying issues that need to be addressed promptly.
● HR 122: A heart rate of 122 beats per minute is elevated and may indicate compensatory mechanisms in response to dehydration or other underlying conditions. It requires further evaluation and intervention.
● Shortness of Breath: This symptom suggests respiratory distress and may be related to the patient's dehydration or underlying conditions. It requires immediate assessment and intervention.
● Temperature 100: An elevated temperature may indicate an underlying infection or inflammatory response. It requires further evaluation to determine the cause and guide appropriate treatment.
● Thirsty: The patient's report of feeling thirsty is an important symptom indicating dehydration and the need for fluid replacement.
● BP 90/50: A blood pressure of 90/50 is low and may be indicative of hypotension, which can occur in dehydration. It requires close monitoring and intervention to stabilize the patient's blood pressure.
The following items are not immediate concerns based on the given information: ● Admitted to the ER: While it is important information, it is not a current concern as the patient is already in the ER.
● Female: The patient's gender is not an immediate concern for the assessment and management of dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Each of your meals should contain about 10 tablespoons of food: After gastric bypass surgery, the stomach's size is reduced, and the patient's capacity to consume large quantities of food is limited. It is important to educate the patient about appropriate portion sizes to avoid overeating and potential complications.
Be certain to stay hydrated by drinking water: Hydration is crucial after gastric bypass surgery. Patients should be advised to drink enough water throughout the day to prevent dehydration and ensure proper bodily function.
Solid food can be introduced back into the diet in a week: Following gastric bypass surgery, the diet is initially limited to liquid and pureed foods. Gradually, solid foods can be reintroduced into the diet over time, typically after a week or as directed by the surgeon. This information is important for the patient to understand the progression of their diet post-surgery. You are likely to have little urine output for the first few weeks: This statement is not true and may cause unnecessary concern for the patient. Urine output should not be affected by gastric bypass surgery unless there are other complications.
Report any back, shoulder, or abdominal pain to the surgeon: While it is important to report any significant pain or discomfort to the surgeon, including back, shoulder, or abdominal pain, this is not specific to discharge teaching for gastric bypass surgery. Pain management and reporting should be covered during the post-operative care instructions, but it is not limited to discharge teaching alone.
Correct Answer is B
Explanation
Loop diuretics, such as furosemide, are known to cause potassium loss as they increase urine output. A potassium level of 1.5 mEq/L indicates severe hypokalemia (low potassium levels), which can be potentially dangerous and lead to various complications, including cardiac arrhythmias.
Hence, it is important to hold the dose of the loop diuretic and notify the physician so that appropriate interventions can be taken to address the low potassium level, such as prescribing potassium supplementation or adjusting the dosage of the loop diuretic.
A sodium level of 144 is within the normal range (135-145 mEq/L) and does not require immediate action.
A blood pressure of 102/78, although it may indicate hypotension, does not necessarily require holding the dose of the loop diuretic unless it is accompanied by other significant symptoms or clinical concerns.
A calcium level of 9 mg/dL falls within the normal range (8.5-10.5 mg/dL) and does not necessitate holding the loop diuretic dose.
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