While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first?

Provide oxygen at 2 L per nasal cannula.

Provide a urinal and encourage the patient to void.

Place the patient in a high Fowler position.

Lay the patient flat in bed to listen to bowel sounds.

Answer and Explanation

The Correct Answer is C

A. Provide oxygen at 2 L per nasal cannula: Although oxygen might be helpful later, the patient currently has a good oxygen saturation (95%). The priority is to ease breathing and reduce fluid accumulation in the lungs.

B. Provide a urinal and encourage the patient to void: While voiding might help reduce fluid volume, repositioning the patient to improve breathing is more urgent.

C. Place the patient in a high Fowler position: This position maximizes lung expansion, improves oxygenation, and helps alleviate dyspnea caused by fluid overload.

D. Lay the patient flat in bed to listen to bowel sounds: Placing the patient flat can worsen pulmonary symptoms by allowing fluid to shift toward the lungs.

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Correct Answer is ["300"]

Explanation

Calculation:

Calculate the duration: From 0330 to 0600 is 2.5 hours.

Multiply the rate by the time:

120mL/hr×2.5hours=300mL.

A. Cardiac dysrhythmias B. Hypoglycemia C. Hyperreflexia D. Increased appetite

Correct Answer is A

Explanation

A. Cardiac dysrhythmias: Hypokalemia impairs cardiac muscle function, potentially leading to arrhythmias such as ventricular tachycardia or premature ventricular contractions.

B. Hypoglycemia: Potassium does not directly cause hypoglycemia; its imbalance more commonly affects cardiac and neuromuscular function.

C. Hyperreflexia: Hypokalemia usually causes muscle weakness and diminished reflexes (hyporeflexia), not hyperreflexia.

D. Increased appetite: Hypokalemia does not typically affect appetite.

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While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

At 0330, a nurse is caring for a client who is postoperative. The client's IV fluids are infusing at 120 mL/hr. How many mL of IV fluid should infuse by 0600? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["300"]

Explanation

A nurse is reviewing the laboratory results of a client who is taking a loop diuretic and notes the client's potassium level is 3.0 mEq/L (3.5-5 mEq/L). Which of the following physiological responses should the nurse expect related to the client's hypokalemia?

Correct Answer is A

Explanation

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