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 B

Explanation

A. Increased bowel sounds: Hypokalemia typically causes decreased bowel activity, leading to constipation or paralytic ileus, rather than increased bowel sounds.

B. Reports of fatigue: Fatigue is a hallmark symptom of hypokalemia due to impaired cellular and muscle function.

C. Positive Trousseau's sign: This is associated with hypocalcemia, not hypokalemia.

D. Reports of numbness in the feet: This is more commonly linked with neuropathy or hypocalcemia, not hypokalemia.

A. Tap the face just below and in front of the ear. B. Inflate a blood pressure cuff around the upper arm for 4 minutes. C. Apply pressure over the ulnar and radial arteries. D. Forcefully dorsiflex the ankle when the knee is in an extended position.

Correct Answer is A

Explanation

A. Tap the face just below and in front of the ear: This is the correct technique for eliciting Chvostek’s sign, which involves tapping over the facial nerve. A positive sign (twitching of facial muscles) indicates hypocalcemia.

B. Inflate a blood pressure cuff around the upper arm for 4 minutes: This describes Trousseau’s sign, another test for hypocalcemia, where carpopedal spasm occurs due to ischemia.

C. Apply pressure over the ulnar and radial arteries: This describes Allen’s test, used to assess arterial blood flow, not calcium levels.

D. Forcefully dorsiflex the ankle when the knee is in an extended position: This describes Homan’s sign, which is used to assess for deep vein thrombosis (DVT), not hypocalcemia.

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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 in a provider's office is collecting data from a client who takes furosemide daily for heart failure. Which of the following findings is a manifestation of hypokalemia?

Correct Answer is B

Explanation

The nurse is using Chvostek sign to assess for hypocalcemia. Which statement correctly describes this test?

Correct Answer is A

Explanation

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