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

Tonic

Hypertonic

Hypotonic

Isotonic

Answer and Explanation

The Correct Answer is B

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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Correct Answer is B

Explanation

Renal failure can cause a buildup of ﬂuid in the body. When kidneys lose their filtering ability, dangerous levels of wastes may accumulate, and your blood’s chemical makeup may get out of balance. This can lead to ﬂuid retention, causing swelling in your legs, ankles or feet.

A. Perform respiratory assessment. B. Document hypoxemia. C. Check the placement of the pulse oximeter. D. Report pulse oximetry to the health care provider.

Correct Answer is A

Explanation

Pulse oximetry is a non-invasive method of monitoring the oxygen saturation level in the blood. A normal range for oxygen saturation is between 95% and 100%. An oxygen saturation level of 89% indicates hypoxemia, which is a serious condition that can lead to tissue damage, organ failure, and even death if left untreated.

Therefore, the priority nursing action is to perform a respiratory assessment to determine the cause of the hypoxemia. This should include assessing the client's airway patency, breathing patern, lung sounds, and oxygen therapy if the client is already receiving it. The nurse should also observe for any signs of respiratory distress such as cyanosis, accessory muscle use, or difficulty breathing.

While it is important to document hypoxemia and report it to the healthcare provider, the priority at this time is to assess and intervene promptly to prevent further deterioration of the client's condition. Checking the placement of the pulse oximeter may be necessary if the reading is unreliable, but it is not the priority in this scenario.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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