Patient Data.
Review H and P, nurses notes, laboratory results, flow sheet, and orders.
Click to mark whether the assessment finding represents a therapeutic result of the sodium bicarbonate administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have one option selected.
Capillary refill 2 seconds
Blood pressure 113/72 mm Hg
Bicarbonate 22 mEq/L (22 mmol/L)
Sodium 152 mEq/L (152 mmol/L)
400 mL urine output
Heart rate 77 beats/minute
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"}}
Choice A: Capillary refill 2 seconds
Reason: Capillary refill time is a quick test to assess peripheral perfusion and hydration status. A normal capillary refill time is less than 2 seconds. Initially, the patient had a capillary refill time of 5 seconds, indicating poor perfusion, likely due to dehydration from vomiting and diarrhea. After the administration of IV fluids and sodium bicarbonate, the capillary refill time improved to 2 seconds, which is within the normal range. This improvement indicates that the treatment was effective in restoring adequate perfusion and hydration, making it a therapeutic result.
Choice B: Blood pressure 113/72 mm Hg
Reason: Normal blood pressure for adults is typically around 120/80 mm Hg. The patient’s initial blood pressure was 100/77 mm Hg, which is on the lower side, likely due to dehydration. After receiving IV fluids and sodium bicarbonate, the blood pressure improved to 113/72 mm Hg, which is closer to the normal range. This indicates that the treatment helped to stabilize the patient’s blood pressure, making it a therapeutic result.
Choice C: Bicarbonate 22 mEq/L (22 mmol/L)
Reason: The normal range for bicarbonate (HCO3) is 21 to 28 mEq/L. The patient’s initial bicarbonate level was 15 mEq/L, indicating metabolic acidosis, likely due to severe vomiting and diarrhea. After the administration of sodium bicarbonate, the bicarbonate level increased to 22 mEq/L, which is within the normal range. This indicates that the sodium bicarbonate effectively corrected the metabolic acidosis, making it a therapeutic result.
Choice D: Sodium 152 mEq/L (152 mmol/L)
Reason: The normal range for sodium is 135 to 145 mEq/L. The patient’s sodium level of 152 mEq/L is above the normal range, indicating hypernatremia. This could be a non-therapeutic side effect of the sodium bicarbonate administration, as sodium bicarbonate can increase sodium levels in the blood. Hypernatremia can lead to symptoms such as confusion, muscle twitching, and seizures, and requires careful monitoring and management.
Choice E: 400 mL urine output
Reason: The patient’s urine output of 400 mL is not directly related to the administration of sodium bicarbonate. Urine output is influenced by various factors, including fluid intake, kidney function, and overall hydration status. In this case, the urine output is more likely related to the patient’s overall fluid balance and hydration status rather than a direct effect of the sodium bicarbonate. Therefore, it is considered an unrelated finding.
Choice F: Heart rate 77 beats/minute
Reason: A normal resting heart rate for adults ranges from 60 to 100 beats per minute. The patient’s initial heart rate was 102 beats per minute, which is elevated, likely due to dehydration and metabolic acidosis. After receiving IV fluids and sodium bicarbonate, the heart rate decreased to 77 beats per minute, which is within the normal range. This indicates that the treatment helped to stabilize the patient’s heart rate, making it a therapeutic result.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Determining the presence of abdominal pain is crucial because long-term use of ibuprofen can lead to gastrointestinal issues, including ulcers and bleeding. Abdominal pain can be an early sign of these complications, and prompt identification is essential to prevent more severe outcomes. Monitoring for gastrointestinal symptoms is a key aspect of managing patients on chronic NSAID therapy.
Choice B Reason:
While palpating the volume of pedal pulses is important for assessing peripheral circulation, it is not directly related to the potential side effects of long-term ibuprofen use. This assessment is more relevant for conditions affecting blood flow, such as peripheral artery disease, rather than for monitoring ibuprofen-related complications.
Choice C Reason:
Evaluating ongoing sleep patterns can provide valuable information about the client’s overall well-being and pain management. However, it is not the most critical assessment in the context of long-term ibuprofen use. Sleep disturbances may be related to chronic pain but are not directly indicative of ibuprofen’s adverse effects.
Choice D Reason:
Assessing back pain using a numeric scale is essential for evaluating the effectiveness of pain management strategies. However, it does not address the potential adverse effects of long-term ibuprofen use. While pain assessment is important, monitoring for signs of gastrointestinal complications takes precedence in this scenario.
Correct Answer is D
Explanation
Choice A Reason:
While keeping skin and eyes covered to protect from sun injury is generally good advice, it is not specifically related to the use of oxybutynin. Oxybutynin can reduce sweating, which increases the risk of overheating and dehydration, especially during physical activities like running a half-marathon. Therefore, this advice, while useful, is not the most critical in this context.
Choice B Reason:
Avoiding crowds to help prevent acquiring infections is important for overall health, especially for individuals with compromised immune systems. However, this advice is not directly related to the use of oxybutynin or the specific risks associated with its use during physical exercise. The primary concern with oxybutynin is its effect on sweating and body temperature regulation.
Choice C Reason:
Wearing padding to protect from bruising if a fall occurs is a precaution that might be relevant for individuals at risk of falls or injuries. However, this advice does not address the specific risks associated with oxybutynin use during physical exercise. The main concern is the potential for overheating and dehydration due to reduced sweating.
Choice D Reason:
Taking measures to avoid dehydration and overheating is the most critical instruction for a client using oxybutynin while training for a half-marathon. Oxybutynin can decrease sweating, making it harder for the body to cool down during exercise. This can lead to heat stroke or severe dehydration. The nurse should emphasize the importance of staying hydrated, taking breaks, and avoiding excessive heat to prevent these serious complications.
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