A nurse is caring for a client who is in shock and is receiving an infusion of albumin.
Which of the following findings should the nurse expect?
Decrease in protein.
Increase in BP.
Oxygen saturation 96%.
PaCO2, 30 mm Hg.
The Correct Answer is B
Albumin is a protein that helps maintain fluid balance in the body by drawing water into the blood vessels. Albumin infusion can increase the blood volume and blood pressure in patients who are in shock due to fluid loss or sepsis.
Choice A is wrong because albumin infusion does not decrease protein levels in the body.
Albumin is a protein itself and adding it to the blood increases the protein concentration.
Choice C is wrong because oxygen saturation of 96% is normal and does not indicate any improvement or deterioration in the patient’s condition.
Choice D is wrong because PaCO2 of 30 mm Hg is low and indicates respiratory alkalosis, which can be caused by hyperventilation, fever, or anxiety. Albumin infusion does not affect PaCO2 levels directly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Distended neck veins are a sign of increased central venous pressure, which can result from fluid volume excess. Fluid volume excess can also cause edema, crackles in the lungs, and increased blood pressure.
Choice A is wrong because decreased bowel sounds are not related to fluid volume excess.
Decreased bowel sounds can indicate ileus, obstruction, or peritonitis. Choice B is wrong because bilateral muscle weakness is not a sign of fluid volume excess.
Bilateral muscle weakness can be caused by electrolyte imbalances, neuromuscular disorders, or stroke.
Choice C is wrong because thready pulse is a sign of fluid volume deficit, not excess.
Thready pulse indicates poor perfusion and low cardiac output, which can result from dehydration, hemorrhage, or shock.
Correct Answer is B
Explanation
Choice A rationale:
The air bubble should not be expelled from the syringe before administering enoxaparin. The air bubble is included to ensure that the entire dose is administered and to help prevent leakage of the medication into the subcutaneous tissue, which can reduce bruising.
Choice B rationale:
After administering enoxaparin, applying firm pressure (but not massaging) to the injection site helps minimize bruising and bleeding. It's important not to massage the site as this can increase the risk of bleeding.
Choice C rationale:
The needle should be inserted fully into the subcutaneous tissue at a 90-degree angle (or at a 45-degree angle if the client has little subcutaneous tissue). Inserting the needle halfway may result in improper administration.
Choice D rationale:
Enoxaparin is a low-molecular-weight heparin that should be administered subcutaneously, not intramuscularly. Administering it intramuscularly could increase the risk of bleeding and is not the appropriate route for this medication.
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