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 D
Explanation
Rationale for Choice A:
While it's important for the primary healthcare provider to be informed about the CD4+ results, it's not the first action the nurse should take. The priority is to implement appropriate infection control measures to protect the patient, other patients, and healthcare staff.
CD4+ cell count is a crucial indicator of the patient's immune status. A count of 180/mm is significantly low, suggesting a weakened immune system and increased vulnerability to infections. However, informing the provider alone doesn't directly address the immediate need for infection control.
Rationale for Choice B:
Airborne Precautions are specifically used for patients with known or suspected airborne infections, such as tuberculosis, measles, or varicella. These precautions involve the use of negative pressure rooms and N95 respirators.
In this case, the patient's TB skin test was negative, indicating no evidence of active tuberculosis infection. Implementing Airborne Precautions unnecessarily could lead to excessive resource utilization and potential stigmatization of the patient.
Rationale for Choice C:
Droplet Precautions are used for patients with infections that can be spread through large respiratory droplets, such as influenza, pertussis, or meningococcal meningitis. These precautions involve the use of masks and eye protection.
While the patient's symptoms of fever, night sweats, and severe cough could be consistent with a droplet-spread infection, there's no definitive evidence to support this at the present time. Initiating Droplet Precautions without a clear indication could also lead to unnecessary resource use and potential anxiety for the patient.
Rationale for Choice D:
Standard Precautions are the foundation of infection control and should be used for all patients, regardless of their known or suspected infection status. These precautions include hand hygiene, use of personal protective equipment (PPE) when indicated, and safe handling of sharps and bodily fluids.
By implementing Standard Precautions, the nurse can effectively minimize the risk of transmission of pathogens, protecting both the patient and other individuals in the healthcare setting. This is the most appropriate first action to ensure a safe and appropriate level of care.
Correct Answer is D
Explanation
Rationale for Choice A:
Hydroxychloroquine does not typically cause hair loss as a significant side effect. While some anecdotal reports have suggested hair thinning as a possibility, it's not a well-established or common occurrence in clinical studies.
If a patient experiences hair loss while on hydroxychloroquine, it's essential to rule out other potential causes, such as underlying medical conditions, stress, or nutritional deficiencies.
It's also important to note that some individuals may have a personal predisposition to hair loss, and medications can sometimes trigger or exacerbate this issue.
Rationale for Choice B:
Hydroxychloroquine is not known to cause a burst of energy. In fact, some patients may experience fatigue or drowsiness as a side effect.
It's crucial to inform patients about potential side effects to manage expectations and promote adherence to treatment.
If a patient experiences unexpected energy changes while taking hydroxychloroquine, it's essential to report this to their healthcare provider for further evaluation.
Rationale for Choice C:
Hydroxychloroquine is generally recommended to be taken with food or milk to reduce potential gastrointestinal side effects such as nausea and vomiting.
Taking it on an empty stomach could increase the risk of these side effects, which could impact medication adherence and effectiveness.
Rationale for Choice D:
Retinal damage is the most serious adverse effect of hydroxychloroquine. It can lead to irreversible vision loss if not detected and managed early.
Patients taking hydroxychloroquine must undergo regular eye examinations to monitor for any signs of retinal toxicity.
Early detection and prompt discontinuation of the medication can often prevent permanent vision loss.
It's crucial for nurses to educate patients about this potential risk and emphasize the importance of regular eye exams.
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