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. Have the laboratory draw a blood sample for an erythrocyte sedimentation rate (ESR): ESR measures inflammation and is unrelated to hyperkalemia.

B. Restrict fluid intake: Fluid restriction is not appropriate for hyperkalemia unless specifically related to fluid overload or renal failure.

C. Obtain a 12-lead ECG: Hyperkalemia can cause life-threatening cardiac dysrhythmias such as peaked T waves, widened QRS complexes, or asystole. ECG monitoring is essential.

D. Administer potassium gluconate 40 mEq orally: This would worsen hyperkalemia and is contraindicated.

A. Increased appetite B. Hyporeflexia C. Constipation D. Headache

Correct Answer is D

Explanation

A. Increased appetite: Hyponatremia does not typically cause increased appetite.

B. Hyporeflexia: Severe hyponatremia may lead to neurological symptoms, but reflex changes are less common.

C. Constipation: This is unrelated to sodium levels.

D. Headache: Hyponatremia causes cellular swelling, including in the brain, leading to headache, nausea, and neurological symptoms.

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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 is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L (3.5 -5 mEq/L). The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has a sodium level of 128 mEq/L (136-145 mEq/L) Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

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