A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data represents an adverse outcome (side effect) of this infusion?
There are crackles throughout both lung fields.
The patient's radial pulse is 105 beats/min.
There is sediment and blood in the patient's urine
The blood pressure increases from 66/50 to 122/74 mm
The Correct Answer is A
A 3% saline solution is a hypertonic solution used to increase serum sodium levels in cases of severe hyponatremia. However, it can lead to fluid overload and pulmonary edema. The presence of crackles throughout both lung fields indicates the accumulation of fluid in the lungs, which is a serious adverse outcome.
The patient's radial pulse rate of 105 beats/min is within a normal range and does not directly indicate an adverse effect of the saline infusion.
The presence of sediment and blood in the patient's urine may be unrelated to the 3% saline infusion and could indicate other issues such as urinary tract infection or kidney injury.
An increase in blood pressure from 66/50 to 122/74 mmHg is an expected effect of a hypertonic solution like 3% saline, as it can cause an increase in intravascular volume. While the increase in blood pressure is significant, it does not represent an adverse outcome specific to the infusion itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Pin site care is essential to prevent infections and other complications associated with external fixation devices. The nurse should instruct the patient to clean the pin insertion sites daily with a sterile saline solution or as per healthcare provider's instructions. The patient should also observe for signs of infection, such as redness, swelling, warmth, and drainage, and report any concerns to the healthcare provider.
Assessing the skin under the foam boot twice daily is not specific to external fixation devices, and it may not be relevant to this patient's care plan. The nurse should focus on teaching the patient about external fixation device care specifically.
Taking prophylactic antibiotics before any dental work for the rest of your life is not relevant to external fixation devices or right lower leg fractures. It is a recommendation for patients with certain heart conditions who may be at risk of developing infective endocarditis during dental procedures.
Removing the external fixator for the shower is not recommended as the device should be kept dry to prevent infections. The nurse should instruct the patient to cover the device with a waterproof dressing or plastic bag during showering to protect it from getting wet.
Correct Answer is A
Explanation
Recombinant human erythropoietin is a medication commonly used in the treatment of anemia associated with chronic renal failure. It stimulates the production of red blood cells in the bone marrow, helping to improve anemia.
The other statements mentioned do not accurately reflect the expected outcomes or effects of recombinant human erythropoietin:
Chronic renal failure leads to impaired kidney function, and while recombinant human erythropoietin can help address anemia, it does not directly improve creatinine (Cr) and blood urea nitrogen (BUN) levels, which are markers of kidney function.
Furosemide is a diuretic commonly used in the management of fluid retention in renal failure. Recombinant human erythropoietin does not replace or eliminate the need for diuretic therapy.
Chronic renal failure typically involves decreased kidney function and impaired urine production. Recombinant human erythropoietin does not directly affect urine output.
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