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","D"]
Explanation
Signs and symptoms associated with a hypersensitivity reaction to cephalosporin antibiotics can include:
1. Skin rash: Hypersensitivity reactions often manifest as skin rashes, which can range from mild to severe. The rash may be itchy, red, raised, and may spread to different areas of the body.
2. Intense pruritus: Pruritus refers to severe itching, which can be a prominent symptom of a hypersensitivity reaction to cephalosporins.
Dizziness and hyperglycemia are not commonly associated with hypersensitivity reactions to cephalosporins. Dizziness may be a side effect of some medications, including antibiotics, but it is not a specific symptom of a hypersensitivity reaction. Hyperglycemia, or high blood sugar levels, is not typically attributed to a hypersensitivity reaction to cephalosporins. It's important to note that hypersensitivity reactions can vary in severity and may include other symptoms such as fever, swelling, difficulty breathing, wheezing, and anaphylaxis. If a hypersensitivity reaction is suspected, it is crucial to seek immediate medical attention for proper evaluation and management.
Correct Answer is C
Explanation
0.9% Sodium chloride is a balanced isotonic solution that closely resembles the electrolyte composition of the extracellular fluid. It is commonly used to treat dehydration because it helps restore fluid volume and electrolyte balance in the body.
5% dextrose in Lactated Ringers: This solution is typically used for fluid and electrolyte replacement in patients who have significant fluid losses or imbalances, but it may not be the best choice for dehydration alone.
0.45% sodium chloride: This solution, also known as half-normal saline, has a lower concentration of sodium chloride and is often used for patients who require hypotonic fluids. It may not provide enough electrolyte replacement for a dehydrated patient. 3% Normal Saline: This solution has a higher concentration of sodium chloride and is typically used for specific indications, such as severe hyponatremia or in critical care settings. It is not the first-line choice for treating dehydration.
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