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 C
Explanation
A low-pressure ventilator alarm indicates a potential issue with the delivery of adequate air or pressure from the ventilator. The pulse oximetry reading of 85% suggests that the client is not receiving sufficient oxygenation.
Providing ventilation with a bag-valve-mask device allows the nurse to manually assist the client's breathing and ensure proper oxygenation and ventilation while troubleshooting the ventilator alarm. By manually ventilating the client, the nurse can help maintain oxygenation and prevent further hypoxemia until the underlying cause of the alarm can be identified and resolved.
Suctioning the client's endotracheal tube, adding air to the pilot balloon, or placing a bit block in the client's mouth may be appropriate interventions in specific situations, but they are not the immediate priority in this case. The primary concern is to address the low oxygen saturation and ensure adequate ventilation.
Correct Answer is D
Explanation
Cephalosporins are similar to another group of beta-lactam antibiotics called the Penicillins. Both cephalosporins and penicillins belong to the beta-lactam class of antibiotics, which share a similar structure and mechanism of action. They inhibit bacterial cell wall synthesis by binding to specific proteins called penicillin-binding proteins (PBPs), leading to bacterial cell death. This shared mechanism of action makes cephalosporins and penicillins similar in their antibacterial effects.
On the other hand, macrolides, fluoroquinolones, and aminoglycosides are different classes of antibiotics with distinct structures and mechanisms of action. They work through different mechanisms to inhibit bacterial growth and have different spectrums of activity compared to beta-lactam antibiotics like cephalosporins and penicillins.
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