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. The medication must be given as a rapid intravenous IV push due to its short half-life not slowly.
B. Asystole is a common and expected response after adenosine administration.
C. Adenosine has a very short half-life, contrary to this statement.
D. The onset of action is immediate, not in 5 minutes.
Correct Answer is B
Explanation
A. Hydration and urine output are maintained through IV fluids and kidney function, not bladder irrigation.
B. Continuous bladder irrigation prevents catheter obstruction by flushing out blood clots or debris after TURP surgery. This is the primary purpose of the procedure.
C. While bladder irrigation may help reduce bleeding indirectly by maintaining flow, it is not its main purpose.
D. Antibiotics are not typically administered via bladder irrigation; systemic routes are preferred for infection control.
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