A client returns to the acute care unit following surgery with 0.9% normal saline infusing at 45 drops/minute through tubing with a drop factor of 60 drops per ml. The postoperative prescriptions include 0.9% normal saline at 75 ml/hour to alternate with Lactated Ringer's solution at 75 ml/hour. An intravenous infusion pump is not available. What action should the nurse implement?
Change the normal saline to a keep open rate until an infusion pump is available.
Increase the rate of the present normal saline infusion to 75 drops per minute.
Leave the normal saline at the current rate until an infusion pump is available.
Switch the saline to Lactated Ringer's solution infusing at 75 drops per minute.
The Correct Answer is C
Choice A: Changing the normal saline to a keep-open rate (KVO) is not appropriate in this situation, as the client has specific fluid orders that need to be followed, and a KVO rate would not provide the prescribed maintenance fluids.
Choice B: Increasing the rate of the present normal saline infusion to 75 drops per minute would not meet the prescription for 0.9% normal saline at 75 ml/hour.
Adjusting the rate this way would require an infusion pump.
Choice C: Leaving the normal saline at the current rate until an infusion pump is available is the most appropriate action. It ensures that the client continues to receive fluids at the ordered rate until the necessary equipment is in place.
Choice D: Switching the saline to Lactated Ringer's solution infusing at 75 drops per minute would not meet the prescribed rate for the normal saline solution. The nurse should follow the specific orders provided.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Uremic frost is a symptom of advanced kidney disease and can result in deposits of urea crystals on the skin. This can cause itching and discomfort, making it difficult for the client to maintain good hygiene and self-care. Therefore, addressing hygiene self-care deficit related to uremic frost is a priority in the plan of care for a client with renal osteodystrophy.
Choice B: This is not directly related to renal osteodystrophy and is more related to the presence of a catheter.
Choice C: This is not typically associated with renal osteodystrophy unless there are specific mobility issues related to bone problems.
Choice D: This may be relevant for clients with CKD, but it is not specific to renal osteodystrophy, which primarily involves bone mineral imbalances.
Correct Answer is B
Explanation
Choice A: Obliterating the entry and inserting the correct information may make the charting less clear and may not be considered a best practice in documentation.
Choice B: Drawing one line through the entry and inserting the correct information is a common method for correcting errors in paper documentation. It maintains clarity while indicating that an error was made and corrected.
Choice C: Charting the correct information in the next column may lead to confusion and does not clearly indicate that an error was made and corrected.
Choice D: Notifying the charge nurse that the entry needs to be revised may be necessary in some situations but is not the first step in correcting a charting error. The error should be corrected at the point of documentation.
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