A nurse is caring for an adult client who has a fever of 39.4°C (103°F) and is receiving 0.9% sodium chloride IV at 125 mL/hr. Over the last hour, the nurse notes that the client's urine output is 20 mL. The nurse should report this finding to the provider and anticipate a prescription for what?
An antipyretic medication
A diuretic medication
A blood culture
A fluid bolus
The Correct Answer is D
Choice A reason: An antipyretic medication is not the best answer because it does not address the client's low urine output. An antipyretic medication is a drug that lowers the body temperature by reducing the production of heat or increasing the loss of heat. It may help the client feel more comfortable, but it does not improve the kidney function or prevent dehydration.
Choice B reason: A diuretic medication is not the best answer because it may worsen the client's low urine output. A diuretic medication is a drug that increases the excretion of water and electrolytes by the kidneys. It may lower the blood pressure and reduce the fluid overload, but it may also cause dehydration, electrolyte imbalance, and kidney damage.
Choice C reason: A blood culture is not the best answer because it does not address the client's low urine output. A blood culture is a laboratory test that detects the presence of bacteria or other microorganisms in the blood. It may help identify the cause of the fever and guide the antibiotic therapy, but it does not improve the kidney function or prevent dehydration.
Choice D reason: A fluid bolus is the best answer because it may improve the client's low urine output. A fluid bolus is a rapid infusion of a large volume of fluid, usually isotonic saline or lactated Ringer's solution. It may increase the blood volume and pressure, improve the tissue perfusion, and stimulate the urine production. It may also help lower the fever by diluting the pyrogens and increasing the heat loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is a correct answer because normal saline is an isotonic solution, which means it has the same osmolarity as the blood plasma. It does not cause any fluid shifts between the intracellular and extracellular compartments, and it can help restore the fluid balance and the blood pressure of the dehydrated client.
Choice B reason: This is not a correct answer because 1/2 normal saline is a hypotonic solution, which means it has a lower osmolarity than the blood plasma. It causes fluid to shift from the extracellular to the intracellular compartment, which can lead to cellular swelling and edema. It is not suitable for rapid infusion, as it can cause hemolysis and hypotension.
Choice C reason: This is not a correct answer because D5W (5% Dextrose in Water) is an isotonic solution when it is in the IV bag, but it becomes hypotonic once it enters the body, as the dextrose is rapidly metabolized and only water remains. It causes fluid to shift from the extracellular to the intracellular compartment, which can lead to cellular swelling and edema. It is not suitable for rapid infusion, as it can cause hemolysis and hypotension.
Choice D reason: This is not a correct answer because D5 1/2 normal saline is a hypertonic solution, which means it has a higher osmolarity than the blood plasma. It causes fluid to shift from the intracellular to the extracellular compartment, which can lead to cellular shrinkage and dehydration. It is not suitable for rapid infusion, as it can cause hypernatremia and fluid overload.
Correct Answer is B
Explanation
Choice A reason: This is not a correct result that the nurse should anticipate. RBC stands for red blood cells, which carry oxygen and carbon dioxide in the blood. The normal range for RBC is 4-5.5 /mm^3^, so a value of 4.2 /mm^3^ is within the normal range and does not indicate any abnormality.
Choice B reason: This is a correct result that the nurse should anticipate. WBC stands for white blood cells, which fight infections and inflammation in the body. The normal range for WBC is 5-10 /mm^3^, so a value of 17 /mm^3^ is above the normal range and indicates leukocytosis, which is an increase in the number of white blood cells. Leukocytosis can be caused by acute appendicitis, as the body tries to fight the infection and inflammation in the appendix.
Choice C reason: This is not a correct result that the nurse should anticipate. Neutrophils are a type of white blood cell that are the first to respond to bacterial infections. The normal range for neutrophils is 3-5.8 /mm^3^, so a value of 3.2 /mm^3^ is within the normal range and does not indicate any abnormality.
Choice D reason: This is not a correct result that the nurse should anticipate. Lymphocytes are a type of white blood cell that are involved in the immune response and the production of antibodies. The normal range for lymphocytes is 1-4 /mm^3^, so a value of 3 /mm^3^ is within the normal range and does not indicate any abnormality.
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