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Exhibits

Given the client's current treatment for fluid volume deficit, what condition(s) should the practical nurse (PN) monitor the client for? Select all that apply.

Thrombocytopenia

Pulmonary edema

Hypokalemia

Alkalosis

Phlebitis

Hyponatremia

Diarrhea and vomiting

Hyperglycemia

Answer and Explanation

Correct Answer : B,C,E

A. Thrombocytopenia
Monitoring for thrombocytopenia is not directly related to the treatment of fluid volume deficit. While it is important to watch for any blood-related issues, thrombocytopenia is not a common concern specifically due to the administration of isotonic fluids like 0.9% sodium chloride. This condition would not be a primary focus in this scenario.
B. Pulmonary edema
The client should be monitored for pulmonary edema as a potential complication of fluid resuscitation. Administering large volumes of isotonic fluids can lead to fluid overload, which may cause pulmonary edema. This is especially important given the presence of pneumonia and the client's symptoms of shortness of breath and crackles in the lung fields.
C. Hypokalemia
Hypokalemia should be monitored as a potential complication of isotonic fluid administration. Although 0.9% sodium chloride does not contain potassium, patients receiving IV fluids for a significant period may develop electrolyte imbalances, including hypokalemia. Monitoring serum electrolytes is necessary to address such imbalances.
D. Alkalosis
Alkalosis is less likely to occur with isotonic fluids like 0.9% sodium chloride. This type of fluid generally does not cause acid-base imbalances such as alkalosis. The treatment for fluid volume deficit is not expected to lead to alkalosis, which is more commonly associated with metabolic alkalosis from other sources.
E. Phlebitis
Phlebitis should be monitored due to the presence of a peripheral IV access device. Long-term or large-volume infusions can irritate the vein, leading to inflammation or phlebitis. Regular inspection of the IV site for redness, swelling, or pain is necessary to prevent and manage this complication.
F. Hyponatremia
Hyponatremia is not a direct concern with isotonic fluids like 0.9% sodium chloride, as these fluids maintain sodium levels without causing a dilution effect. Monitoring sodium levels is generally more relevant in cases where hypotonic fluids are used.
G. Diarrhea and vomiting
Diarrhea and vomiting are not directly related to isotonic fluid administration. Although these symptoms can contribute to fluid volume deficits, they are not a common complication of fluid resuscitation.
H. Hyperglycemia
Hyperglycemia is not a concern with isotonic fluids like 0.9% sodium chloride. Hyperglycemia is more associated with fluids containing glucose, such as dextrose solutions. Therefore, monitoring for hyperglycemia is not necessary in this context

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Correct Answer is D

Explanation

A. Administering ketorolac does not require specific timing in relation to meals. It can be given with or without food, but the key considerations are related to the drug’s effects rather than meal timing.
B. Ketorolac does not require peak and trough serum level monitoring. This practice is more relevant for medications with narrow therapeutic ranges or those requiring precise dosage adjustments, which is not the case for ketorolac.
C. Observing for involuntary movements of the lips and tongue is not a primary concern for ketorolac therapy. This is more relevant to medications like antipsychotics that can cause extrapyramidal symptoms.
D. Assessing the skin daily for signs of bleeding is crucial because ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding due to its effects on platelet function and gastrointestinal mucosa.

A. Report any foot injury or sore that does not readily heal. B. After washing feet, dry thoroughly between toes. C. Make sure shoe size fits to minimize rubbing and blisters. D. Monitor fingerstick glucose daily for tight control.

Correct Answer is A

Explanation

A. Reporting any foot injury or sore that does not readily heal is the most crucial instruction for minimizing long-term complications in diabetes management. Poor circulation and neuropathy in diabetic patients can lead to serious complications from minor foot injuries, so prompt medical evaluation is essential for preventing severe outcomes.
B. Drying feet thoroughly between toes is important for preventing fungal infections, but it is a standard part of foot care rather than a primary measure for preventing long-term complications like ulcers or infections.
C. Ensuring that shoe size fits to minimize rubbing and blisters is important for foot health, but it is not as critical as promptly addressing any injuries or sores that may arise.
D. Monitoring fingerstick glucose daily for tight control is necessary for diabetes management but does not directly address foot care issues. It is important for overall disease management but not specifically for immediate foot care concerns.

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Exhibits Given the client's current treatment for fluid volume deficit, what condition(s) should the practical nurse (PN) monitor the client for? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is assisting with the plan of care for a client who is receiving the nonsteroidal anti-inflammatory drug ketorolac for painful muscle spasms of the back. Which intervention should the PN include in the client's plan of care?

Correct Answer is D

Explanation

Which foot care instruction is most important for the practical nurse (PN) to reinforce that minimizes a long-term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)?

Correct Answer is A

Explanation

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Exhibits

Given the client's current treatment for fluid volume deficit, what condition(s) should the practical nurse (PN) monitor the client for? Select all that apply.