Which IV solution would the nurse anticipate administering to a patient with fluid deficit who requires isotonic fluid replacement?

Choice A: Collect patient information

This is the first step in the nursing process, known as the assessment phase. During this phase, the nurse gathers comprehensive information about the patient’s health status, including medical history, physical examination findings, and any relevant diagnostic test results. This information forms the foundation for identifying the patient’s health needs and planning appropriate care.

Choice B: Identify any clinical problems

The second step is the diagnosis phase, where the nurse analyzes the collected data to identify the patient’s health problems. These problems can be actual or potential issues that require nursing intervention. Accurate identification of clinical problems is crucial for developing an effective care plan.

Choice C: Decide a plan of action

The third step is the planning phase. In this phase, the nurse sets measurable and achievable goals for the patient’s care and decides on the appropriate nursing interventions to address the identified clinical problems. The plan of action should be individualized to meet the specific needs of the patient.

Choice D: Carry out the plan

The fourth step is the implementation phase, where the nurse executes the planned interventions. This may involve administering medications, providing education, performing procedures, or coordinating with other healthcare professionals. The goal is to achieve the desired patient outcomes as outlined in the care plan.

Choice E: Determine whether the plan was effective

The final step is the evaluation phase. In this phase, the nurse assesses the patient’s response to the implemented interventions and determines whether the goals of the care plan have been met. If the desired outcomes are not achieved, the nurse may need to revise the care plan and repeat the process.

Choice A Reason:
Monitoring the CXR (chest X-ray) results is not directly related to assessing myelosuppression. A chest X-ray is typically used to evaluate the lungs and heart, and while it can help identify infections or other complications, it does not provide information about bone marrow activity or blood cell counts. Myelosuppression specifically affects the production of blood cells in the bone marrow, which is best assessed through blood tests like the CBC (Complete Blood Count).
Choice B Reason:
Monitoring the BMP (Basic Metabolic Panel), especially the sodium, potassium, and magnesium counts, is important for evaluating electrolyte balance and kidney function. However, it does not directly assess myelosuppression. Myelosuppression involves the suppression of bone marrow activity, leading to decreased production of blood cells, which is not reflected in electrolyte levels.
Choice C Reason:
Monitoring the CBC (Complete Blood Count), especially the neutrophil, platelet, and RBC (red blood cell) counts, is the most appropriate method for assessing myelosuppression. Myelosuppression results in decreased production of blood cells, including neutrophils (a type of white blood cell), platelets, and red blood cells. A CBC provides detailed information about these cell counts and helps identify conditions like neutropenia (low neutrophil count), thrombocytopenia (low platelet count), and anemia (low red blood cell count), which are common consequences of myelosuppression.
Choice D Reason:
Monitoring the spinal fluid analysis is not relevant for assessing myelosuppression. Spinal fluid analysis is typically used to diagnose conditions affecting the central nervous system, such as infections, bleeding, or multiple sclerosis. It does not provide information about bone marrow activity or blood cell counts, which are the primary concerns in myelosuppression.