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?
Oxygen saturation 96%
Decrease in protein
Increase in BP
PaCO2 30 mm Hg
The Correct Answer is C
Choice A Reason:
Oxygen saturation within this range is generally considered adequate and might not directly correlate with the administration of albumin.
Choice B Reason:
Decrease in protein is incorrect. Albumin infusions are meant to supplement protein levels in the blood, so a decrease in protein wouldn't be an expected finding.
Choice C Reason:
Increase in blood pressure is correct. Albumin infusions can potentially help increase blood volume, leading to an increase in blood pressure. In shock, where there's a significant decrease in blood pressure due to reduced circulating volume, administering albumin or other intravenous fluids can help restore blood volume and consequently raise blood pressure towards a more stable range.
Choice D Reason:
PaCO2 of 30 mm Hg is incorrect. PaCO2 levels are related to respiratory function and the amount of carbon dioxide in the blood. While shock can impact various physiological parameters, a PaCO2 level of 30 mm Hg alone might not be directly tied to the administration of albumin in shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason:
"I should avoid drinking grapefruit juice." This statement is actually accurate. Grapefruit juice can interfere with the metabolism of certain statin medications, including lovastatin, leading to increased levels of the drug in the body. Advising against grapefruit juice consumption is a recommended precaution when taking lovastatin, so this statement shows the client's understanding of this interaction.
Choice B Reason:
"I am trying to decrease my dietary fat intake." This statement reflects a positive lifestyle change. Lowering dietary fat intake is often recommended for individuals on statin medications to help manage cholesterol levels. This statement demonstrates the client's commitment to making healthy dietary adjustments, which aligns with the treatment plan.
Choice B Reason:
"I was just diagnosed with hepatitis B. "Hepatitis B can affect liver function, and statin medications like lovastatin can potentially impact liver enzymes. Therefore, in someone with a history of hepatitis B, it's crucial to assess liver function before starting a statin and to monitor the liver during treatment. This statement raises concerns about potential liver complications or interactions that require further evaluation before initiating lovastatin.
Choice D Reason:
"I take metformin for my diabetes." Metformin, a medication for diabetes, does not directly interact with lovastatin. While it's relevant to know the client's other medications, this statement doesn't indicate a need for immediate further assessment regarding the use of lovastatin.
Correct Answer is D
Explanation
Choice A Reason:
Weight gain is incorrect. Weight gain is typically associated with fluid volume excess rather than deficit. In heart failure, fluid retention can lead to weight gain due to excess fluid accumulation in the body.
Choice B Reason:
Distended neck veins is incorrect. Distended neck veins are a sign of fluid volume excess, commonly seen in heart failure due to increased venous pressure and fluid retention.
Choice C Reason:
Shortness of breath is incorrect.: Shortness of breath is often associated with fluid accumulation in the lungs, known as pulmonary edema, which is a manifestation of fluid volume excess or fluid overload in heart failure.
Choice D Reason:
Elevated hematocrit level is correct. Furosemide is a diuretic that promotes diuresis (increased urine output), leading to fluid loss. When a client experiences fluid volume deficit or dehydration due to increased diuresis, there is a concentration of red blood cells in the blood, resulting in an elevated hematocrit level. This occurs because the blood becomes more concentrated when there's less fluid volume available.
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