The practical nurse (PN) heard adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour. Which action should the PN take next?
Report the findings to the charge nurse.
Review the last balance of intake and output.
Slow the DSW infusion rate to 50 ml/hour.
Document the findings and monitor the client.
The Correct Answer is A
The practical nurse (PN) who hears adventitious breath sounds while auscultating the lungs of an older adult who is receiving an IV of 5% dextrose in water (DW) at 100 mL/hour should report the findings to the charge nurse.
Adventitious breath sounds can be indicative of respiratory problems such as fluid accumulation or infection in the lungs. In this case, it is important for the PN to report the findings to the charge nurse to ensure appropriate action is taken to assess and manage the client's respiratory status.
incorrect:
B- Reviewing the last balance of intake and output is important for overall assessment but may not directly address the concern of adventitious breath sounds. It can provide additional information about the client's fluid balance, but it is not the next immediate action in response to the abnormal lung sounds.
C- Slowing the DSW infusion rate to 50 mL/hour is not the most appropriate action to take based solely on the presence of adventitious breath sounds. The abnormal lung sounds may be an indication of an underlying respiratory issue that needs further evaluation and intervention.
Adjusting the infusion rate without a comprehensive assessment and appropriate medical orders could potentially overlook the underlying cause.
D- Documenting the findings and monitoring the client is necessary, but it should not be the sole action taken. Reporting the findings to the charge nurse is crucial to ensure prompt assessment and appropriate intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Hemodialysis is a procedure used to remove waste products and excess fluid from the blood when the kidneys are unable to function properly. One of the waste products that accumulate in the blood during kidney dysfunction is creatinine. Creatinine is a byproduct of muscle metabolism, and its levels in the blood are normally regulated and eliminated by the kidneys. In AKI, the kidneys are not able to effectively filter and eliminate creatinine, leading to elevated levels in the blood. Hemodialysis helps to remove excess creatinine from the blood, resulting in decreased creatinine levels.
A- Elevated potassium levels (hyperkalemia) are common in AKI and can be life-threatening. Hemodialysis helps to remove excess potassium from the blood, restoring normal levels.
However, the best indicator of the effectiveness of hemodialysis in managing hyperkalemia would be monitoring the potassium levels before and after the session rather than considering it as the "best" indicator.
B- Decreased calcium levels can occur in kidney dysfunction due to impaired activation of vitamin D and decreased absorption of calcium from the intestines. While hemodialysis can help restore calcium levels, it may not be the primary laboratory value used to evaluate the effectiveness of each session.
C- Lowered hemoglobin levels can be seen in AKI due to various factors, including decreased production of red blood cells and blood loss. Hemodialysis can help remove waste products and excess fluid, but it may not directly address the underlying causes of lowered hemoglobin levels.
Correct Answer is B
Explanation
Antiplatelet medications, such as aspirin or clopidogrel, are prescribed to prevent the formation of blood clots by inhibiting platelet aggregation. These medications can increase the risk of bleeding or prolonged bleeding time. Therefore, when removing the saline lock, applying pressure over the site for several minutes helps to minimize the risk of bleeding and promote hemostasis.
A. Leaving the saline lock in place and notifying the charge nurse may not be necessary unless there are specific concerns or complications related to the client's condition.
C. Encouraging the client to drink additional oral fluids is not directly related to the discontinuation of the saline lock and the potential risk of bleeding associated with antiplatelet medication.
D. Preparing a warm pack to apply after removing the lock is not necessary for this situation. Warm packs are typically used for comfort or to promote circulation, but they are not directly related to the risk of bleeding associated with antiplatelet medication.
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