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
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wearing gloves during breakfast service is not always required, and the focus should be on ensuring proper hand hygiene rather than glove use.
B. The hand rub should be completed in 20-30 seconds, and the UAP’s 2-minute hand rub is excessive. Proper hand hygiene techniques should be reinforced.
C. The UAP does not need to remain in the client's room during hand hygiene; the primary issue is the duration of the hand rub.
D. Inspecting the hands for cleanliness is not necessary if the hand hygiene practice is incorrect; instead, correcting the technique is more important.
Correct Answer is ["A","D","E"]
Explanation
A. Oatmeal is a good choice for breakfast.
Oatmeal is a good source of iron and can be part of a vegetarian diet. It is a suitable option for increasing iron intake while adhering to vegetarian dietary restrictions.
B. Eat red meat just until the anemia is resolved.
This option is not suitable for a vegetarian client. Red meat is a source of heme iron, but it conflicts with the client’s dietary preferences and does not align with a vegetarian diet.
C. Take two prenatal vitamins with iron daily.
Doubling the dose of prenatal vitamins is not recommended without specific advice from a healthcare provider. The prescribed dosage should be followed, and dietary changes should be the focus.
D. Add lentils and black beans to soups.
Lentils and black beans are excellent sources of non-heme iron, which fits well within a vegetarian diet. Including these foods in meals can help boost iron levels effectively.
E. Increase green leafy vegetables in the diet.
Green leafy vegetables are high in non-heme iron and are suitable for vegetarians. Increasing their consumption supports iron intake and helps manage anemia.
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