Patient Profile:

Age: 68 years

Gender: Male

Medical History: Hypertension, Type 2 Diabetes Mellitus

Medications: Lisinopril, Metformin

Allergies: None

Chief Complaint: The patient presents to the emergency department (ED) with sudden onset of right-sided weakness and difficulty speaking that began approximately 1 hour prior to arrival.

Exhibits

Choose three parameters the nurse should monitor to assess the patient's progress.

Respiratory status

Liver enzymes

Blood pressure

Neurological status

Potassium level

Answer and Explanation

Correct Answer : A,C,D

Choice A reason: Respiratory status is crucial to monitor because patients with acute neurological deficits, such as those seen in strokes, are at risk of respiratory compromise. This can be due to weakened respiratory muscles or aspiration, which could lead to pneumonia or other respiratory complications.

Choice B reason: Monitoring liver enzymes is not directly related to the acute management of a stroke patient. Liver enzymes would be more relevant in cases where liver function or hepatic issues are suspected, but not for this specific scenario.

Choice C reason: Blood pressure monitoring is vital, as hypertension is a significant risk factor for stroke. Maintaining appropriate blood pressure is essential to prevent further neurological damage and complications. Acute changes in blood pressure can indicate worsening or improvement of the patient's condition.

Choice D reason: Neurological status should be continuously monitored to assess the progression of the patient's stroke symptoms. This includes checking for changes in level of consciousness, motor function, speech, and other neurological signs. Prompt detection of changes can guide immediate interventions.

Choice E reason: Potassium level monitoring is not a primary focus in the acute management of stroke. While electrolyte balance is important, it is not as critical as respiratory status, blood pressure, and neurological status in this context.

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Correct Answer is C

Explanation

Choice A reason: Eating foods high in potassium can be important for patients taking diuretics, as diuretics can cause potassium loss. However, for SIADH patients, this is not a primary focus unless they are on diuretics that specifically lead to potassium loss.

Choice B reason: Limiting fluid intake is crucial for patients with SIADH to prevent fluid overload and hyponatremia. This statement aligns with proper management of the condition.

Choice C reason: Patients with SIADH need to carefully manage their sodium intake. Rather than reducing sodium, they often need to maintain or increase their sodium intake to help counteract the effects of SIADH, which causes dilutional hyponatremia (low blood sodium levels). Therefore, this statement indicates a need for additional instruction.

Choice D reason: Weighing oneself daily is an important practice for SIADH patients to monitor for sudden weight changes, which can indicate fluid imbalances. This statement is appropriate and does not require additional instruction.

A. 0.45% sodium chloride B. 0.9% sodium chloride C. 5% dextrose in 0.9% sodium chloride D. 5% dextrose in 0.45% sodium chloride

Correct Answer is B

Explanation

Choice A reason: 0.45% sodium chloride is a hypotonic solution, which is not ideal for rapidly replacing fluid volume in patients with low blood pressure due to severe diarrhea. Hypotonic solutions can cause fluid to move into cells rather than staying in the vascular space, potentially worsening hypotension.

Choice B reason: 0.9% sodium chloride, also known as normal saline, is an isotonic solution. It is the best choice for rapidly replacing fluid volume in patients with low blood pressure. Isotonic solutions stay in the vascular space and help restore circulating blood volume and blood pressure without causing fluid shifts that can lead to cellular edema or dehydration.

Choice C reason: 5% dextrose in 0.9% sodium chloride is a hypertonic solution, which might not be the most appropriate for initial rapid fluid resuscitation. Hypertonic solutions can draw fluid into the vascular space from the interstitial and intracellular spaces, potentially leading to rapid changes in fluid balance and electrolyte shifts.

Choice D reason: 5% dextrose in 0.45% sodium chloride is also a hypertonic solution but with a hypotonic component (0.45% sodium chloride). This combination is not typically used for rapid fluid resuscitation because it can cause fluid shifts that are less predictable and may complicate the patient's electrolyte balance and hydration status.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which patient statement indicates to the nurse that additional instruction is needed for a patient with chronic syndrome of inappropriate antidiuretic hormone (SIADH)?

Correct Answer is C

Explanation

The nurse admits a patient with a low BP who reports severe diarrhea for several days from a Clostridium difficile infection. Which IV fluid would the nurse associate with the need to rapidly replace the patient's fluid volume?

Correct Answer is B

Explanation

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The health care provider prescribes IV vancomycin for a patient with pneumonia. Which priority action should the nurse perform before the first dose of the antibiotic?

The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?

The nurse is planning to administer a transfusion of packed red blood cells (PRBCs) to a patient with blood loss from a gastrointestinal hemorrhage. Which action can the nurse delegate to the nursing assistant (unlicensed assistive personnel)?

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