A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider?

Patient has not voided for the last 4 hours.

Crackles are heard halfway up the posterior chest.

Skin is dry with poor turgor on all extremities.

Patient has had 5 loose stools over the last 6 hours.

Answer and Explanation

The Correct Answer is B

Choice A reason: A lack of voiding for 4 hours in a dehydrated patient is a significant finding that requires monitoring; however, it is expected during the early stages of rehydration as the body conserves fluid. While the nurse should continue to monitor output, it does not represent an immediate life-threatening complication of the current IV therapy.

Choice B reason: The presence of crackles halfway up the posterior chest in an older adult receiving rapid IV fluid replacement indicates fluid volume excess and pulmonary edema. This is a critical priority because the patient's respiratory status is compromised, and it suggests the heart or kidneys cannot tolerate the 125 mL/hour rate.

Choice C reason: Dry skin and poor turgor are expected clinical manifestations of the dehydration for which the patient is currently being treated. While these findings confirm the initial diagnosis, they do not indicate a new or worsening complication arising from the treatment itself, unlike the development of adventitious lung sounds.

Choice D reason: Loose stools are a characteristic symptom of an ulcerative colitis exacerbation. Having 5 stools over 6 hours indicates that the inflammatory process is still active, but it is not as acutely dangerous as the development of pulmonary congestion due to circulatory overload from the intravenous fluid administration.

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Correct Answer is B

Explanation

Choice A reason: Hypernatremia refers to elevated serum sodium levels. Sodium polystyrene sulfonate is a cation-exchange resin that actually exchanges sodium ions for potassium ions in the intestine. Administering this medication would potentially increase sodium levels further, which would be contraindicated in a patient already suffering from hypernatremia.

Choice B reason: Hyperkalemia is a life-threatening complication of acute kidney injury due to the kidneys' inability to excrete excess potassium. Sodium polystyrene sulfonate works by binding potassium in the gastrointestinal tract in exchange for sodium, allowing the excess potassium to be excreted via the feces, thereby lowering serum potassium levels.

Choice C reason: Hypercalcemia is an elevation in serum calcium. This medication is not indicated for calcium imbalances. In the context of renal failure, patients are more likely to experience hypocalcemia due to impaired vitamin D activation and hyperphosphatemia, rather than hypercalcemia, which usually involves different pharmacological interventions like bisphosphonates.

Choice D reason: Hypomagnesemia is a low level of magnesium. Sodium polystyrene sulfonate is specifically designed to target potassium exchange. It does not provide a mechanism for increasing magnesium levels. Electrolyte replacement therapy, usually via magnesium sulfate, would be required to correct a magnesium deficiency in a clinical setting.

A. "Do you have insurance to cover this drug?" B. "Do you have any allergy to sulfa drugs?" C. "Are you taking Vitamin C or B?" D. "Can you swallow pills pretty easily?"

Correct Answer is B

Explanation

Choice A reason: Determining insurance coverage is a logistical concern related to medication adherence and healthcare access. While important for ensuring the client can obtain the treatment, it is not a clinical priority or a safety screening question required before the administration of a potentially high-risk pharmacological agent.

Choice B reason: Sulfasalazine is a compound of 5-aminosalicylic acid and sulfapyridine. It is contraindicated in patients with known hypersensitivity to sulfonamides or salicylates. Asking about allergies is the highest priority to prevent life-threatening Type 1 hypersensitivity reactions, such as anaphylaxis, or severe cutaneous adverse reactions like Stevens-Johnson syndrome.

Choice C reason: Inquiring about vitamins is relevant because sulfasalazine can interfere with the absorption of folic acid (Vitamin B9), often requiring supplementation. However, this is a secondary management concern. The immediate safety priority is screening for allergies that could cause an acute, severe systemic reaction upon the first dose.

Choice D reason: Assessing the ability to swallow pills is a practical consideration for oral medication administration. If a patient has dysphagia, the nurse might need an alternative formulation. However, this does not carry the same clinical weight as screening for a drug allergy that could lead to significant medical morbidity.

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A 72-year-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client in acute kidney injury (AKI). Which complication would most clearly warrant the administration of polystyrene sulfonate?

Correct Answer is B

Explanation

The nurse is caring for a client who is prescribed sulfasalazine. Which question would the nurse ask the client before starting this drug?

Correct Answer is B

Explanation

The nurse is providing discharge teaching for a 21-year-old client with a new diagnosis of ulcerative colitis. When planning family assessment, the nurse should recognize that which of the following factors will likely have the greatest impact on the client's coping after discharge?

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