A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment?
Urine specific gravity 1.020.
Potassium 5.2 mEq/L.
Hct 6296.
Sodium 165 mEq/L.
The Correct Answer is A
Urine specific gravity 1.020.
Choice A rationale:
Urine specific gravity is a measure of urine concentration, indicating the ability of the kidneys to concentrate or dilute urine. A specific gravity of 1.020 falls within the normal range (typically 1.010 to 1.030). An appropriate specific gravity indicates that the client's kidneys are responding well to the IV fluids, maintaining adequate urine output and concentration.
Choice B rationale:
Potassium level of 5.2 mEq/L is above the normal range of 3.5 to 5 mEq/L. However, this value does not specifically indicate whether the client is responding effectively to the IV fluids for dehydration.
Choice C rationale:
Hct (Hematocrit) of 6296 is not a valid measurement; it appears to be a typographical error or an incomplete value. Therefore, it cannot be used to assess the client's response to treatment.
Choice D rationale:
Sodium level of 165 mEq/L is elevated beyond the normal range of 136 to 145 mEq/L. However, this value does not provide information about the client's response to IV fluids for dehydration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E"]
Explanation
The correct answer is choiceC. Monitor the injection site for redness,D. Use an infusion controller for the IV, andE. Monitor fluid intake and output.
Choice A rationale:
Adding the ordered dose to the IV hanging is incorrect because potassium chloride should never be added to an already hanging IV solution due to the risk of uneven distribution and potential overdose.
Choice B rationale:
Administering the dose IV push over 3 minutes is incorrect because potassium chloride should never be given by direct IV injection.It must always be diluted and administered slowly to prevent cardiac complications.
Choice C rationale:
Monitoring the injection site for redness is correct because potassium chloride can cause irritation and phlebitis at the injection site.
Choice D rationale:
Using an infusion controller for the IV is correct because it ensures the potassium chloride is administered at a controlled rate, reducing the risk of rapid infusion and potential cardiac issues.
Choice E rationale:
Monitoring fluid intake and output is correct because it helps assess the patient’s overall fluid balance and detect any signs of fluid overload or deficit, which is crucial when administering potassium.
Correct Answer is ["B","C","E"]
Explanation
Choice A rationale:
Dysrhythmias are not a direct consequence of diabetic ketoacidosis (DKA) or the acid-base imbalance indicated by the patient's pH of 7.2 and bicarbonate level of 20 mEq/L. DKA primarily affects the respiratory system, leading to Kussmaul respirations, not dysrhythmias.
Choice B rationale:
Kussmaul respirations are an expected finding in a patient with diabetic ketoacidosis (DKA) and metabolic acidosis. These deep, rapid breaths are the body's attempt to compensate for the acidosis by eliminating excess CO2.
Choice C rationale:
Weakness is a common symptom of DKA. The hyperglycemia and acidosis result in intracellular dehydration and impaired cellular function, leading to weakness and fatigue.
Choice D rationale:
Cold, clammy skin is not typically associated with DKA. Instead, patients with DKA may have warm, dry skin due to dehydration and impaired thermoregulation.
Choice E rationale:
Tachycardia is an expected finding in a patient with DKA. The metabolic acidosis and dehydration lead to an increase in heart rate as the body attempts to maintain perfusion.
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