RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:

Chart the reading at 91%, this is normal for a COPD patient.

Place a non-rebreather on the patient with high ﬂow oxygen.

Call the doctor if the patient is declining.

Sit the patient up and have them breathe deep.

Answer and Explanation

The Correct Answer is D

Sitting the patient up and encouraging deep breathing can help improve oxygenation and increase the pulse oximetry reading. This is a non-invasive intervention that can be implemented immediately to help improve the patient’s oxygen levels.

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Correct Answer is B

Explanation

Fluid retention is a common complication in heart failure, and monitoring the client's ﬂuid status is crucial to manage the condition eﬀectively. Daily weights are an essential component of monitoring ﬂuid status and are the most sensitive and practical method to detect changes in the client's ﬂuid status. Weight gain is a reliable indicator of ﬂuid retention, and even small increases in weight can indicate the need for changes in the client's treatment plan.

Although electrolyte monitoring (option a), output measurements (option c), and daily BUN and serum creatinine monitoring (option d) can provide valuable information about the client's ﬂuid status, they are not as sensitive or practical as daily weights. Electrolyte monitoring can help detect changes in ﬂuid balance, but it does not provide a direct indication of ﬂuid status. Output measurements can indicate ﬂuid loss, but they do not provide an accurate assessment of ﬂuid retention. BUN and serum creatinine monitoring can detect changes in renal function, but they are not specific to ﬂuid status.

A. Tonic B. Hypertonic C. Hypotonic D. Isotonic

Correct Answer is B

Explanation

Hypertonic solutions have a higher concentration of solutes (such as sodium, glucose, or mannitol) than the ﬂuid in the body's cells, causing water to move out of the cells and into the bloodstream. This results in the shrinking of the cells and an increase in extracellular ﬂuid volume.

Examples of hypertonic solutions include 10% dextrose in water (D10W), 3% saline, and 5% dextrose in 0.9% saline.

In contrast, isotonic solutions have the same concentration of solutes as the ﬂuid in the body's cells, and hypotonic solutions have a lower concentration of solutes than the ﬂuid in the body's cells.

Therefore, in this scenario, the nurse should administer a hypertonic solution to the client who requires IV ﬂuids.

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RH has a history of COPD. The CNA checks his vital signs at the beginning of the shift and tells you that his pulse ox reading is 91%. What should the nurse advise the CAN does next:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client admited with heart failure requires careful monitoring of his ﬂuid status. Which method will provide the nurse with the best indication of the client’s ﬂuid status?

Correct Answer is B

Explanation

The nurse is caring for a client who requires IV ﬂuids. which IV ﬂuid type would be considered a hypertonic solution?

Correct Answer is B

Explanation

Your patient has a CMP drawn to determine their electrolytes. Only part of the values have resulted including the Na+ which is 121 mEq/l. What type of electrolyte imbalance is the patient having?

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