Exhibits

Review H and P, nurse's note, laboratory results, prescriptions, and imaging studies.

What complications should the practical nurse (PN) monitor for in the next 6 to 8 hours? Select all that apply.

A. Respiratory rate 18 breaths/minute
The respiratory rate is within the normal range for an adult (12-20 breaths/minute). No immediate follow-up is required for this vital sign.
B. Heart rate 101 beats/minute
An elevated heart rate (tachycardia) can indicate several issues, including fever, infection, or pain. In the context of a surgical site infection and elevated temperature, tachycardia is a sign of systemic response and needs to be evaluated further to determine the cause and appropriate intervention.
C. Capillary refill 2 seconds
Capillary refill time of 2 seconds is within the normal range (≤ 2 seconds) and indicates adequate perfusion. No immediate follow-up is needed.
D. Breath sounds clear and equal bilaterally
This finding indicates no acute respiratory issues. No immediate follow-up is necessary based on this assessment.
E. Turban dressing is saturated with serosanguinous drainage
Saturation of the dressing with serosanguinous drainage indicates a significant amount of wound drainage, which could suggest worsening of the infection or a new complication. This finding requires immediate follow-up to assess the wound and determine if additional interventions or changes in treatment are necessary.
F. Blood pressure 140/84 mm Hg
While slightly elevated, this blood pressure reading is not excessively abnormal and does not require immediate follow-up in the absence of other symptoms. Monitoring is required but not urgent.
G. Temperature 101.9° F (38.8° C)
An elevated temperature indicates a fever, which is a sign of infection. Given the positive MRSA culture and the need for infection control, this temperature warrants immediate follow-up to assess for worsening infection and determine the need for antipyretics or antibiotics.
H. Client is awake and alert
Being awake and alert is a positive finding and does not require immediate follow-up

A. 50% dextrose
50% dextrose is not isotonic; it is a hypertonic solution. Hypertonic solutions have a higher concentration of solutes compared to the cells, causing water to move out of the cells and into the extracellular space, which does not treat fluid volume deficit effectively.
B. 0.45% sodium chloride
0.45% sodium chloride, also known as half-normal saline, is a hypotonic solution. Hypotonic solutions have a lower concentration of solutes compared to the cells, which would cause water to move into the cells rather than stay in the extracellular space to address fluid volume deficit.
C. 20% dextrose
20% dextrose is a hypertonic solution. It contains a higher concentration of dextrose compared to the extracellular fluid, which draws water into the extracellular space but is not used for treating fluid volume deficits.
D. 5% dextrose
5% dextrose (D5W) is initially isotonic but becomes hypotonic once metabolized, as the dextrose is used up and only water remains. It is not suitable for continuous isotonic fluid therapy for fluid volume deficit.
E. 5% dextrose with 0.45% sodium chloride
5% dextrose with 0.45% sodium chloride is a hypertonic solution. While it starts isotonic, it becomes hypotonic once the dextrose is metabolized, making it unsuitable for long-term isotonic fluid replacement.
F. 5% dextrose with lactated Ringer's
5% dextrose with lactated Ringer's is a hypertonic solution. It contains both dextrose and electrolytes, which are not purely isotonic and may not be ideal for addressing fluid volume deficits on their own.
G. Lactated Ringer's
Lactated Ringer's is an isotonic solution. It has a similar osmolarity to plasma and is used for fluid volume replacement, helping to restore blood volume and maintain electrolyte balance.
H. 0.9% sodium chloride
0.9% sodium chloride, or normal saline, is an isotonic solution. It has the same osmolarity as plasma and is commonly used for fluid volume replacement and maintaining hydration