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 C

Explanation

A. Hypertension: Low calcium levels are not typically associated with hypertension. In fact, hypocalcemia can lead to a variety of neurological symptoms such as muscle spasms and tetany.

B. Increased thirst: Increased thirst is not a direct symptom of hypocalcemia. It may be seen in diabetes or dehydration but not typically in hypocalcemia.

C. Muscle tetany: Hypocalcemia is a common result of thyroidectomy, especially if the parathyroid glands were affected during surgery. This condition can lead to muscle tetany, which involves involuntary muscle contractions or spasms.

D. Diaphoresis: Diaphoresis is not commonly associated with hypocalcemia. Sweating is more related to stress, pain, or fever.

A. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution. B. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution. C. Notify the physician D. Check for kinking of the tubing or a closed clamp.

Correct Answer is D

Explanation

A. Turn off the IV solution and gently flush the line with 3 mL of saline flush solution: This may be necessary later if the occlusion is not resolved by troubleshooting, but the first action should be to check the tubing and clamp for any obstructions.

B. Decrease the rate to 10 mL/hr and flush the line with 1 mL of heparin solution: This is not appropriate as an initial action. Heparin flushes are generally used for maintaining patency in central lines and are not indicated for occlusions caused by tubing issues.

C. Notify the physician: While important if the issue persists, this is not the first action. The nurse should attempt to resolve the problem independently first.

D. Check for kinking of the tubing or a closed clamp: This is the first action the nurse should take. Most occlusions are due to kinking in the tubing or a closed clamp, and resolving this issue may immediately restore the flow.

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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

A nurse reviewing the laboratory of a client who had a total thyroidectomy discovers that his calcium level is 7 mg/dL (9-10.5 mg/dL). Which of the following client findings should the nurse expect?

Correct Answer is C

Explanation

The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?

Correct Answer is D

Explanation

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