What nursing assessments/interventions should be completed prior to administering Isotonic IV solutions? (Select all that apply)
Elevate the head of the bed to 35-45 degrees unless contraindicated
Assess Vital Signs
Recheck MD orders post infusion
Assess lung and heart sounds
Obtain baseline weight
Review labs post infusion
Correct Answer : A,B,D,E
Choice A rationale:
Elevate the head of the bed to 35-45 degrees unless contraindicated:
Promotes venous return: Elevating the head of the bed reduces venous pooling in the lower extremities and promotes venous return to the heart. This helps to improve cardiac output and reduce the risk of fluid overload.
Reduces aspiration risk: Elevating the head of the bed also helps to prevent aspiration, as it keeps the head and neck in a more upright position. This allows for better drainage of secretions and reduces the chance of them entering the lungs.
Contraindications: There are a few contraindications to elevating the head of the bed, such as severe hypotension, head injury, or spinal injury. In these cases, the potential benefits of elevation must be weighed against the risks.
Choice B rationale:
Assess Vital Signs:
Baseline assessment: It's crucial to obtain baseline vital signs before administering any IV fluid to have a reference point for comparison. This allows for early detection of any changes that may indicate fluid overload or other complications.
Monitoring fluid status: Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, provide important information about the patient's fluid status and hemodynamic stability. Changes in vital signs can signal fluid overload, dehydration, or other problems that may require intervention.
Detecting adverse reactions: Vital signs can also help to detect adverse reactions to the IV fluid, such as allergic reactions or anaphylaxis. Early identification of these reactions is essential for prompt treatment.
Choice D rationale:
Assess lung and heart sounds:
Baseline assessment: Assessing lung and heart sounds before IV fluid administration provides a baseline for comparison and helps to identify any preexisting conditions that may affect fluid tolerance.
Detecting fluid overload: Crackles in the lungs, increased heart rate, and extra heart sounds can indicate fluid overload, which can lead to pulmonary edema and heart failure.
Monitoring response to therapy: Lung and heart sounds can also be used to monitor the patient's response to IV fluid therapy. Improvement in lung sounds and heart rate can indicate a positive response to treatment.
Choice E rationale:
Obtain baseline weight:
Accurate fluid balance: Obtaining a baseline weight is essential for accurate assessment of fluid balance. It allows for tracking of fluid gains and losses and helps to prevent fluid overload or dehydration.
Monitoring fluid status: Changes in weight can reflect changes in fluid status. Weight gain can indicate fluid retention, while weight loss can suggest dehydration.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Affiliation with a medical or nursing school can offer some benefits, but it's not the most crucial factor to consider when seeking a new job.
Nurses in these facilities may have opportunities for professional development and involvement in research, but these benefits might not be available to all nurses.
The quality of the work environment, staffing levels, and support for nurses can vary significantly in facilities affiliated with schools.
Prioritizing Magnet status ensures a focus on nursing excellence and a commitment to providing a supportive work environment.
Choice B rationale:
Having the latest technology can be appealing, but it doesn't guarantee a positive work experience for nurses.
The most important factors for job satisfaction and quality patient care are often related to the work environment, staffing levels, and leadership support.
Magnet hospitals prioritize these factors, leading to better outcomes for both nurses and patients.
Choice C rationale:
Inquiring about nurse-patient ratios is essential, but it's not the only indicator of a positive work environment.
Magnet hospitals typically have favorable nurse-patient ratios, but they also excel in other areas that contribute to job satisfaction and quality care.
These areas include: shared governance, leadership support, professional development opportunities, and a focus on evidence-based practice.
Choice D rationale:
Magnet status is the highest recognition a hospital can achieve for nursing excellence.
It signifies a commitment to: quality patient care, positive work environments for nurses, professional development, and shared governance.
Research consistently demonstrates that Magnet hospitals have: lower nurse turnover rates, higher patient satisfaction scores, and better patient outcomes.
Seeking employment in a Magnet hospital is the most beneficial advice for a nurse looking for a job that prioritizes nursing excellence, job satisfaction, and quality patient care.
Correct Answer is D
Explanation
Rationale for Choice A:
Documentation is essential for communication and continuity of care, but it is not the most immediate priority in this situation.
The nurse should document the episode of vomiting, including the time, amount, and characteristics of the vomitus, as well as any associated symptoms or interventions.
However, auscultating lung sounds should be done first to assess for potential aspiration, which is a more urgent concern.
Rationale for Choice B:
Offering dry toast may be appropriate after the nurse has assessed for aspiration and determined that it is safe for the client to resume oral intake.
However, it is not the most important action at this time.
The nurse should first assess the client's respiratory status and address any potential complications.
Rationale for Choice C:
Rest is important for healing and recovery, but it is not the most immediate priority in this situation. The nurse should first assess the client's respiratory status and address any potential complications. Once the client is stable, the nurse can then encourage rest.
Rationale for Choice D:
Auscultating lung sounds is the most important action for the nurse to take after a client vomits.
This is because aspiration of vomitus is a serious complication that can lead to pneumonia, respiratory distress, and even death.
By auscultating lung sounds, the nurse can assess for signs of aspiration, such as crackles, wheezing, or diminished breath sounds.
If aspiration is suspected, the nurse can initiate appropriate interventions, such as suctioning, oxygen therapy, and positioning the client to facilitate drainage of secretions.
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