A nurse is caring for a client who has major burns and is experiencing dehydration. The nurse should anticipate a prescription to infuse which of the following solutions?
0.45% sodium chloride
Lactated Ringer's
Dextrose 5% in water
Dextrose 5% in 0.45% sodium chloride
The Correct Answer is B
A. 0.45% sodium chloride: 0.45% sodium chloride solution, also known as half-normal saline, is a hypotonic solution used for rehydration and maintenance fluid therapy. However, in cases of
major burns where there is a significant loss of fluid and electrolytes, isotonic solutions are generally preferred.
B. Lactated Ringer's: Lactated Ringer's solution is an isotonic crystalloid solution that closely resembles the electrolyte composition of extracellular fluid. It is commonly used for fluid resuscitation in clients with major burns to replace lost fluids and electrolytes and restore
intravascular volume.
C. Dextrose 5% in water: Dextrose 5% in water is a hypotonic solution used primarily for hydration in clients with normal electrolyte levels or as a vehicle for administering medications.
It is not typically used for fluid resuscitation in clients with major burns, as it does not adequately replace lost electrolytes.
D. Dextrose 5% in 0.45% sodium chloride: This solution combines dextrose 5% and 0.45% sodium chloride and is used for maintenance fluid therapy and mild dehydration. However, in cases of major burns where there is significant fluid and electrolyte loss, isotonic solutions like lactated Ringer's or normal saline are preferred for fluid resuscitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hang the TPN solution to gravity to infuse: TPN solutions are typically administered using an infusion pump to control the rate of infusion accurately. Hanging the solution to gravity is not recommended because it may lead to inconsistent flow rates and inaccurate delivery of nutrients.
B. Titrate TPN solution to blood pressure: TPN solutions are not titrated based on blood pressure.
The composition and rate of TPN infusion are typically determined by the client's nutritional needs and metabolic status, not blood pressure.
C. Monitor the client's weight daily: Monitoring the client's weight daily is essential when administering TPN to assess for fluid balance, nutritional status, and response to therapy. Changes in weight can indicate fluid retention, dehydration, or changes in nutritional status, which may require adjustments to the TPN regimen.
D. Obtain the client's blood glucose level weekly: Blood glucose levels should be monitored frequently in clients receiving TPN, as hyperglycemia is a common complication. Weekly monitoring may not be sufficient to detect and manage hyperglycemia promptly. Therefore,
blood glucose levels are typically monitored more frequently, such as multiple times daily or according to institutional protocols.
Correct Answer is A
Explanation
A. Hypotension: Hypotension can occur as an adverse effect of fentanyl, particularly if the client experiences excessive sedation or respiratory depression. Fentanyl is a potent opioid analgesic
that can cause vasodilation and a decrease in blood pressure, especially when used in high doses or in susceptible individuals.
B. Tachycardia: Tachycardia is not a typical adverse effect of fentanyl. Opioids like fentanyl typically cause bradycardia or have minimal effects on heart rate.
C. Diarrhea: Diarrhea is not a common adverse effect of fentanyl. Opioids more commonly cause constipation due to their effects on gastrointestinal motility.
D. Insomnia: Insomnia is not a typical adverse effect of fentanyl. Opioids typically cause sedation and can lead to drowsiness or somnolence, especially during initial use or when administered in high doses.
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