A nurse is administering dextrose 10% in water (D10W) to a patient who needs some nutrition with glucose. Which of the following assessments should the nurse perform? (Select all that apply.)

Monitor blood glucose levels.

Check for signs of phlebitis at the IV site.

Assess for fluid overload.

Evaluate serum sodium levels.

Observe for signs of hypoglycemia.

Answer and Explanation

Correct Answer : A,B,C

Choice A reason:

The nurse should monitor blood glucose levels because dextrose 10% in water (D10W) is a hypertonic solution that contains glucose and can raise the blood sugar level of the patient. The nurse should check the blood glucose level before and after administering D10W to prevent hyperglycemia or hypoglycemia.

Choice B reason:

The nurse should check for signs of phlebitis at the IV site because D10W is acidic and can cause venous irritation. Phlebitis is inflammation of the vein that can result from chemical, mechanical or bacterial causes. Signs of phlebitis include pain, redness, swelling, warmth and tenderness at the IV site.

Choice C reason:

The nurse should assess for fluid overload because D10W is quickly metabolized, leaving behind water that can move into the interstitial space. Fluid overload can cause edema, dyspnea, crackles, distended neck veins, increased blood pressure and decreased urine output. The nurse should monitor the intake and output, vital signs, weight and breath sounds of the patient.

Choice D reason:

The nurse does not need to evaluate serum sodium levels because D10W does not contain sodium or affect the sodium balance of the patient. D10W is used to provide some nutrition with glucose, not to correct electrolyte imbalances.

Choice E reason:

The nurse does not need to observe for signs of hypoglycemia because D10W is unlikely to cause hypoglycemia unless there is a sudden interruption or discontinuation of the infusion. Hypoglycemia is a low blood sugar level that can cause shakiness, diaphoresis, confusion, weakness, hunger and headache. The nurse should monitor the blood glucose level and administer D10W at a steady rate to prevent hypoglycemia.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason:

Serum glucose 600 mg/dL. This is an expected finding for a client who has diabetic ketoacidosis (DKA) DKA results from a deficiency of insulin, which leads to hyperglycemia and ketosis. The normal range for serum glucose is 70 to 110 mg/dL.

Choice B reason:

Serum bicarbonate 28 mEq/L. This is not an expected finding for a client who has DKA. A client who has DKA experiences ketosis, which results in ketones in the urine and blood. The nurse should expect a client who has DKA to have an HCO3- less than 15 mEq/L. This decreased value is due to an increased production of ketones, which results in metabolic acidosis. The normal range for serum bicarbonate is 22 to 26 mEq/L.

Choice C reason:

Serum potassium 2.5 mEq/L. This is not an expected finding for a client who has DKA. A client who has DKA experiences osmotic diuresis and subsequent dehydration, which can cause electrolyte imbalances. The nurse should expect a client who has DKA to have elevated serum potassium levels due to the movement of potassium from the intracellular to the extracellular space in response to acidosis. The normal range for serum potassium is 3.5 to 5 mEq/L.

Choice D reason:

Serum sodium 150 mEq/L. This is not an expected finding for a client who has DKA. A client who has DKA experiences osmotic diuresis and subsequent dehydration, which can cause electrolyte imbalances. The nurse should expect a client who has DKA to have decreased serum sodium levels due to the dilutional effect of excess glucose in the blood. The normal range for serum sodium is 136 to 145 mEq/L.

A. pH 7.50, PaCO2 40 mm Hg, HCO3- 30 mEq/L. B. pH 7.35, PaCO2 35 mm Hg, HCO3- 24 mEq/L. C. pH 7.25, PaCO2 50 mm Hg, HCO3- 26 mEq/L. D. pH 7.30, PaCO2 30 mm Hg, HCO3- 18 mEq/L.

Correct Answer is A

Explanation

Choice A reason:

pH 7.50, PaCO2 40 mm Hg, HCO3- 30 mEq/L. This choice is correct because it shows a high pH, a normal PaCO2, and a high HCO3-, which are consistent with metabolic alkalosis. Metabolic alkalosis occurs when there is a loss of acid or a gain of base in the body fluids, such as from prolonged nasogastric suctioning. The kidneys try to compensate by excreting more bicarbonate, but this process is slow and incomplete.

Choice B reason:

pH 7.35, PaCO2 35 mm Hg, HCO3- 24 mEq/L. This choice is incorrect because it shows normal values for pH, PaCO2, and HCO3-, which indicate no acid-base imbalance. A client with metabolic alkalosis would have an elevated pH and bicarbonate level.

Choice C reason:

pH 7.25, PaCO2 50 mm Hg, HCO3- 26 mEq/L. This choice is incorrect because it shows a low pH, a high PaCO2, and a normal HCO3-, which are consistent with respiratory acidosis. Respiratory acidosis occurs when there is impaired gas exchange or hypoventilation, leading to an accumulation of carbon dioxide in the blood. The kidneys try to compensate by retaining more bicarbonate, but this process is slow and incomplete.

Choice D reason:

pH 7.30, PaCO2 30 mm Hg, HCO3- 18 mEq/L. This choice is incorrect because it shows a low pH, a low PaCO2, and a low HCO3-, which are consistent with metabolic acidosis. Metabolic acidosis occurs when there is a gain of acid or a loss of base in the body fluids, such as from diabetic ketoacidosis or diarrhea. The lungs try to compensate by increasing the rate and depth of breathing to expel more carbon dioxide, but this process is fast and limited.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is administering dextrose 10% in water (D10W) to a patient who needs some nutrition with glucose. Which of the following assessments should the nurse perform? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the laboratory report of a client who has diabetic ketoacidosis (DKA) Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is caring for a client who has metabolic alkalosis as a result of prolonged nasogastric suctioning. The nurse should expect which of the following arterial blood gas values?

Correct Answer is A

Explanation

A nurse is caring for a client who has dehydration due to vomiting and diarrhea. The client's blood pressure is 90/60 mm Hg, pulse is 110/min, and respirations are 22/min. The nurse should anticipate a prescription for which of the following types of IV fluids?

A nurse is administering dextrose 10% in water (D10W) to a patient who needs some nutrition with glucose. Which of the following assessments should the nurse perform? (Select all that apply.)

A nurse is planning care for a client who has hyponatremia and is receiving IV fluid therapy with 3% sodium chloride solution. Which of the following interventions should the nurse include in the plan? (Select all that apply.)

The nurse is preparing to hang a bag of 0.9% sodium chloride (normal saline) for a patient who has hyponatremia. The nurse knows that this type of solution is:

A nurse is evaluating a client who has fluid volume overload and received furosemide 40 mg IV bolus 1 hr ago. Which of the following findings indicates that the medication was effective?

The nurse is preparing to insert a central venous catheter into a patient's right internal jugular vein using ultrasound guidance. What is an important step that the nurse should perform before inserting the catheter?