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.

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Correct Answer is B

Explanation

Choice A: Hypercalcemia. This is a condition of having too much calcium in the blood. It can cause muscle weakness, constipation, nausea, vomiting, confusion, and irregular heartbeat. However, it does not typically cause paresthesias (tingling or numbness), diarrhea, or crackles in the lungs.

Choice B:

Hypokalemia. This is a condition of having too low potassium in the blood. It can cause muscle weakness, paresthesias, irregular heartbeat, shallow respirations, and increased risk of digoxin toxicity (a medication used to treat heart failure) It can also cause vomiting and diarrhea, which can worsen the potassium loss. This choice matches the symptoms of the patient.

Choice C:

Hypermagnesemia. This is a condition of having too much magnesium in the blood. It can cause muscle weakness, nausea, vomiting, low blood pressure, bradycardia (slow heart rate), and respiratory depression. However, it does not usually cause paresthesias, diarrhea, or crackles in the lungs.

Choice D:

Hypophosphatemia. This is a condition of having too low phosphate in the blood. It can cause muscle weakness, bone pain, rickets (softening of bones), and impaired cellular function. However, it does not typically cause paresthesias, irregular heartbeat, shallow respirations, or crackles in the lungs.

A. Kussmaul respirations. B. Bradypnea. C. Muscle spasms. D. Numbness and tingling of extremities.

Correct Answer is A

Explanation

Choice A reason:

Kussmaul respirations are a type of deep, rapid breathing that occurs in response to metabolic acidosis. The body tries to compensate for the excess acid by blowing off carbon dioxide through the lungs. Kussmaul respirations are a common manifestation of diabetic ketoacidosis (DKA), which is a severe form of metabolic acidosis caused by the accumulation of ketones in the blood. The nurse should monitor the client's respiratory rate, depth, and pattern, as well as the arterial blood gas results, to assess the severity of metabolic acidosis and the effectiveness of treatment.

Choice B reason:

Bradypnea is a condition of abnormally slow breathing, usually less than 12 breaths per minute. Bradypnea can result from respiratory acidosis, which is a condition of excess carbon dioxide in the blood due to hypoventilation or impaired gas exchange. Bradypnea is not a manifestation of metabolic acidosis, which is a condition of excess acid in the blood due to increased production or decreased elimination of hydrogen ions. Therefore, choice B is incorrect.

Choice C reason:

Muscle spasms are involuntary contractions of the skeletal muscles that can cause pain and discomfort. Muscle spasms can result from hypocalcemia, which is a condition of low calcium levels in the blood. Hypocalcemia can occur in metabolic acidosis due to the binding of calcium with excess hydrogen ions, reducing the availability of free calcium for muscle contraction. However, muscle spasms are not a specific or common manifestation of metabolic acidosis, and they can have other causes such as dehydration, electrolyte imbalance, or muscle injury. Therefore, choice C is incorrect.

Choice D reason:

Numbness and tingling of extremities are sensations of reduced or abnormal feeling in the arms or legs. Numbness and tingling can result from hypokalemia, which is a condition of low potassium levels in the blood. Hypokalemia can occur in metabolic acidosis due to the movement of potassium from the intracellular to the extracellular space in exchange for hydrogen ions, which are then excreted by the kidneys. However, numbness and tingling are not specific or common manifestations of metabolic acidosis, and they can have other causes such as nerve compression, peripheral neuropathy, or hyperventilation. Therefore, choice D is incorrect.

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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.)

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Correct Answer is B

Explanation

A nurse is caring for a client who has metabolic acidosis due to diabetic ketoacidosis (DKA) Which of the following manifestations should the nurse monitor?

Correct Answer is A

Explanation

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