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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
This statement belongs to the "Request" portion of the SBAR format. It articulates a specific action the nurse wants the healthcare provider to take.
It's not part of the Background because it doesn't provide any historical or contextual information about the patient's condition.
Choice B rationale:
This statement is the correct choice for the "Background" portion of the SBAR format.
It provides essential background information about the patient's recent medical history, specifically the recent hysterectomy.
This information is crucial for the healthcare provider to understand the context of the current situation and make informed decisions about pain management.
Choice C rationale:
This statement provides additional patient information, but it's not the most relevant for the Background section in this context.
The patient's aversion to NSAIDs might be important for medication choices, but it doesn't directly address the current issue of pain management after a hysterectomy.
Choice D rationale:
This statement provides important information about the patient's allergies, but it's not the most relevant for the Background section in this context.
Allergies are crucial for medication safety, but they don't directly address the current issue of pain management or provide context about the patient's recent surgery.
Correct Answer is D
Explanation
Choice A: Clarify that these precautions are mandated by law.
While it's important to acknowledge the legal requirements for Contact Precautions, this approach alone may not adequately address the family's emotional concerns and fears. It could potentially increase their anxiety if they feel forced to visit without understanding the reasons behind the precautions.
Choice B: Emphasize the importance of their visit to the patient.
While family support is crucial for the patient's well-being, emphasizing the importance of their visit without addressing their fears could inadvertently pressure them to visit without feeling comfortable or confident in their ability to protect themselves.
Choice C: Assure the family that they will not contract the infection.
It's not always possible to guarantee that the family won't contract the infection. Making such assurances could create a false sense of security and potentially lead to lapses in infection control practices.
Choice D: Demonstrate to the family how to prevent the spread of the disease.
Empowering the family through education and demonstration is the most effective approach. It addresses their concerns directly, promotes understanding, and instills confidence in their ability to protect themselves while visiting.
Key elements of this demonstration include:
Proper hand hygiene techniques
Use of personal protective equipment (PPE) such as gloves and gowns Safe handling of potentially contaminated items
Maintaining a safe distance from the patient when appropriate Understanding the modes of transmission for the specific disease
By providing clear guidance and allowing for practice, the nurse can help the family feel more comfortable and confident in their ability to visit safely.
Additional considerations:
Addressing the family's emotional concerns: Acknowledge their fears and provide reassurance in a compassionate and understanding manner.
Tailoring education to the family's level of understanding: Use simple language and visual aids as needed.
Encouraging questions and open communication: Create a supportive environment where the family feels comfortable asking questions and expressing their concerns.
Collaborating with other healthcare professionals: Involve infection control specialists or other relevant team members to provide additional support and expertise.
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