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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Sodium polystyrene sulfonate (Kayexalate): This medication is used to treat hyperkalemia (high potassium levels) by exchanging sodium ions for potassium ions in the intestines, which helps lower potassium levels. The client’s potassium level is dangerously high at 6.2 mEq/L, so this is the most appropriate treatment.
B. Lactulose: Lactulose is used to treat hyperammonemia in liver failure or constipation. It has no role in managing elevated potassium levels.
C. Acetylcysteine: Acetylcysteine is used to treat acetaminophen overdose or as a mucolytic. It is not indicated for hyperkalemia.
D. Potassium iodide: Potassium iodide is used to protect the thyroid from radiation exposure or to treat certain types of thyroid conditions, not for hyperkalemia.
Correct Answer is ["125"]
Explanation
To calculate the IV rate:
Rate(mL/hr) = Total volume /Time in hours
Rate(mL/hr) = 3000 ml /24 hrs
=125mL/hr
So, the IV pump should be set to 125 mL/hr.
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