A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Slow infusion rate and contact the provider.

Lower the head of the bed to semi-Fowler's.

Administer prescribed corticosteroids.

Change infusion to lactated Ringer's and maintain rate.

Answer and Explanation

The Correct Answer is A

A.   The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B.   Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C.   Administering corticosteroids is not indicated based on the client's symptoms and situation.
D.   Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.

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Correct Answer is B

Explanation

A) Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary risk associated with the observations noted.
B) A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection. Additionally, if the urinary catheter bag is not positioned below the level of the bladder, urine can reflux back into the bladder, which also increases the risk of infection.
C) Neurogenic bladder is a condition typically associated with nerve damage, not directly related to the position of the catheter bag or kinked tubing.
D) Phlebitis is inflammation of a vein, which would not be directly caused by the issues noted with the urinary catheter.

A. Frequent diarrhea B. Urinary hesitancy C. Unexplained weight gain D. Painless vaginal bleeding

Correct Answer is D

Explanation

A. Frequent diarrhea is not typically associated with cervical cancer.

B. Urinary hesitancy is more commonly associated with prostate issues in males rather than cervical cancer in females.
C. Unexplained weight gain is not typically a symptom of cervical cancer.

D. Painless vaginal bleeding, especially after intercourse or between periods, can be a sign of cervical cancer. It's essential for individuals to seek medical evaluation if they experience any abnormal bleeding.

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A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

Correct Answer is B

Explanation

A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?

Correct Answer is D

Explanation

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