75-year-old who lives alone, is admitted to the hospital because of weakness and confusion.
Physical Examination
Confusion, slow to respond to questioning, generalized weakness, decreased skin turgor, dry mucous membranes, peripheral pulses weak.
Vitals: T: 101 F, BP 90/62, HR 120 bpm and irregular, RR 24, Sp02 89% on room air.
Central Venous Pressure (CVP): 1 mmHg
Pulmonary Arterial Wedge Pressure (PAWP): 2 mmHg.
Test Name |
Results |
Reference Range |
WBC |
12, 000 |
4, 000- 11, 000 |
Na+ |
149 mEq/L |
135-145 mEq/L |
K+ |
5.0 mEq/L |
3.5- 5.0 mEq/L |
Cl- |
110 mEq/L |
96-106 mEq/L |
pH |
7.34 |
7.35-7.45 |
PaCO2 |
34 mmHg |
35- 45 mmHg |
PaO2 |
78 mm Hg |
80-100 mmHg |
HCO3 |
21 mEq/L |
22- 26 mEq/L |
What order by the health care provider should the nurse question?
Increase 0.9% Normal Saline infusion to 250 ml/hr per protocol.
Collect blood cultures and start Vancomycin 1gm IV.
Collect UA for culture and sensitivity.
Administer Furosemide (Lasix) 20mg IV push.
The Correct Answer is D
A. Increasing normal saline infusion is appropriate for treating dehydration and hypovolemia.
B. Collecting blood cultures and administering antibiotics is appropriate for treating possible sepsis, given the fever and elevated WBC count.
C. Collecting a urine sample for culture and sensitivity is appropriate to investigate a potential urinary source of infection.
D. Administering furosemide, a diuretic, is inappropriate in a client with signs of dehydration and hypovolemia (e.g., low CVP and PAWP) as it can worsen fluid depletion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Lantus insulin does not directly affect potassium levels in the same way that digoxin does.
B. A potassium level of 3.0 mEq/L is low, and digoxin toxicity can occur when potassium levels are low, leading to an increased risk of arrhythmias. This requires immediate attention to avoid serious complications.
C. Metoprolol is a beta-blocker that does not directly cause hypokalemia and is less of an immediate concern.
D. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that could affect kidney function but does not directly impact potassium levels as significantly as digoxin.
Correct Answer is ["900"]
Explanation
Calculate the actual urine output:
Total output - Irrigation solution = Actual urine output
2500 mL (total output) - 1600 mL (irrigation solution) = 900 mL (actual urine output)
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