A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement.
Which of the following findings should the nurse identify as effectiveness of the treatment?
Urine output 200 mL/4 hr.
Heart rate 104/min.
Peripheral pulses +1.
Urine specific gravity 1.04. .
The Correct Answer is A
Choice A rationale:
The nurse should identify that an effective outcome of IV fluid replacement in a client with dehydration is an increase in urine output. Urine output of 200 mL in 4 hours indicates that the kidneys are responding to the IV fluid replacement, and the client is likely rehydrating. This suggests that the renal perfusion has improved, and the client's body is eliminating waste products properly.
Choice B rationale:
A heart rate of 104 beats per minute is not necessarily indicative of the effectiveness of IV fluid replacement. Heart rate may vary for various reasons, and it is not a specific parameter for assessing the response to hydration. Other factors, such as blood pressure, should be considered to evaluate cardiovascular status.
Choice C rationale:
Peripheral pulses of +1 are not a direct indicator of the effectiveness of IV fluid replacement. While improved hydration may lead to better peripheral perfusion, this assessment is somewhat subjective and may not accurately reflect the overall effectiveness of the treatment.
Choice D rationale:
A urine specific gravity of 1.04 is not indicative of the effectiveness of IV fluid replacement. A specific gravity of 1.004 is within the normal range (normal range: 1.005-1.030) and does not necessarily indicate hydration status. It is essential to focus on urine output and other objective parameters to assess the effectiveness of hydration therapy. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
The nurse should seek clarification for the prescribed medication Propranolol when caring for a client with an exacerbation of asthma. Propranolol is a non-selective beta-blocker, and its use can exacerbate bronchoconstriction and potentially worsen asthma symptoms. In patients with asthma, non-selective beta-blockers are generally contraindicated. The nurse should consult with the provider to ensure that Propranolol is the appropriate choice, as there may be safer alternatives to manage the client's condition without worsening their asthma.
Choice A rationale:
Prednisone is a corticosteroid commonly used to reduce inflammation and manage asthma exacerbations. It is an appropriate medication for asthma management and does not require clarification.
Choice B rationale:
Montelukast is a leukotriene receptor antagonist that is also used in the management of asthma. It helps to reduce airway inflammation and bronchoconstriction. Montelukast is an appropriate choice for asthma and does not need further clarification.
Choice C rationale:
Aminophylline is a bronchodilator that can be used in the treatment of asthma. While it may have potential side effects and interactions, it is not the first medication that needs clarification in this scenario. Propranolol, due to its potential to worsen asthma symptoms, takes precedence.
Correct Answer is D
Explanation
Choice A rationale:
Having the client cough and expectorate secretions is a reasonable intervention for managing respiratory distress, but it is not the top priority. The nurse should first assess the client's overall respiratory status to determine the severity of the problem.
Choice B rationale:
Instructing the client to use a pursed-lip breathing technique is a helpful strategy to improve breathing in some cases. However, it should not be the top priority when a client is experiencing difficulty breathing. Assessment should come first.
Choice C rationale:
Increasing the oxygen flow to 3 L/min without a proper assessment is not advisable. It's essential to evaluate the client's respiratory status before making any adjustments to the oxygen therapy.
Choice D rationale:
"Evaluate the client's respiratory status" is the correct response. When a client with COPD and oxygen therapy reports difficulty breathing, the nurse's priority is to assess the client's respiratory status. This assessment will help determine the cause of the breathing difficulty and guide appropriate interventions. The nurse should also check the oxygen saturation levels, respiratory rate, and auscultate lung sounds to assess the severity of the issue.
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