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 B
Explanation
Choice A rationale:
Elevating the head of the bed to a 45-degree angle is important for clients with obstructive sleep apnea (OSA) to help prevent airway obstruction during sleep. However, this should not be the nurse's immediate priority before leaving the client. Ensuring the client's positive airway pressure (PAP) device is properly applied is more crucial.
Choice C rationale:
While locking the side rails in place is generally essential for safety, it is not the most critical intervention for a client with OSA and urination issues. Ensuring proper use of the PAP device is a higher priority.
Choice D rationale:
Removing dentures or other oral appliances is important for preventing airway obstruction in clients with OSA, but it should not take precedence over ensuring the use of the PAP device. The nurse should address the immediate respiratory needs of the client.
Correct Answer is A
Explanation
Choice A rationale:
Restricting visitation is an essential intervention during an influenza outbreak in a long-term care facility. Influenza is highly contagious and can spread rapidly among residents and staff in a close environment like a long-term care facility. By limiting visitation, the facility can reduce the risk of introducing the virus from the outside and help contain the outbreak. This is a preventive measure to protect vulnerable residents from exposure to the virus.
Choice B rationale:
Providing prophylactic antibiotics for clients who have been exposed to influenza is not a recommended intervention. Influenza is caused by a virus, not bacteria, so antibiotics are ineffective in preventing or treating the infection. Antibiotics should only be used to treat bacterial infections, not viral ones. Inappropriate use of antibiotics can lead to antibiotic resistance and other adverse effects.
Choice C rationale:
Implementing airborne precautions for clients who have influenza is not typically necessary. Influenza primarily spreads through respiratory droplets when an infected person coughs or sneezes. Standard precautions, such as proper hand hygiene and wearing masks when in close contact with infected individuals, are usually sufficient to prevent the spread of the virus. Airborne precautions are typically reserved for diseases that are transmitted through the airborne route, like tuberculosis.
Choice D rationale:
Assigning healthcare personnel to nondirect care activities for 24 hours after developing influenza symptoms is not a recommended intervention. While it's important for healthcare personnel to stay home when they are sick to prevent the spread of the virus, 24 hours may not be a necessary duration. The standard guideline for healthcare workers with influenza is to stay home until they are fever-free for at least 24 hours without the use of fever-reducing medications.
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