A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?

Reference Range:

Blood glucose (70 to 110 mg/dL (less than 6.1 mmol/L)] Amylase [60 to 120 units/dL (30 to 220 units/L)]

Blood urea nitrogen (BUN) [10 to 20 mg/dL (3.6 to 7.1 mmol/L)]

Hematocrit (HCT) [42% to 52% (0.42 to 0.52 volume fraction)]

An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction).

An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L).

A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).

A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);

Answer and Explanation

The Correct Answer is C

A.   This would indicate fluid volume deficit, not improvement. Increasing IV fluids should lead to a decrease in hematocrit, not an increase.
B.   This is not a desired outcome for a patient with pancreatitis, as hyperglycemia is a common complication. The focus should be on maintaining stable blood glucose levels.
C.   BUN is a marker of kidney function and hydration status. A decrease in BUN indicates improved renal perfusion, which is a therapeutic outcome of increasing IV fluids.
D.   While a decrease in amylase is generally a good sign for pancreatitis, it is not a direct result of increasing IV fluids. Amylase levels decrease as the pancreatitis improves.

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Correct Answer is A

Explanation

A. Clear breath sounds indicate effective ventilation and oxygenation, which are the desired outcomes of incentive spirometry. This outcome directly reflects the effectiveness of the incentive spirometer in preventing atelectasis and improving lung expansion.
B. A productive cough suggests mobilization of secretions. While this is important for airway clearance, it is not a direct measure of the effectiveness of the incentive spirometer. This outcome is related to airway clearance, but not specifically to the incentive spirometer's role in lung expansion.
C. This outcome measures the client's ability to use the device correctly but does not assess the effectiveness of the device in improving lung function. This outcome is important but does not directly address the goal of the incentive spirometer.
D. This outcome measures compliance with the therapy but does not assess its effectiveness in improving lung function. This outcome is important for adherence but does not directly address the goal of the incentive spirometer.

A. High risk for injury related to increased intracranial pressure. B. Alteration in comfort related to motor vehicle collision. C. Alteration in nutrition related to poor dietary intake. D. Anxiety related to unknown outcome of automobile repairs.

Correct Answer is A

Explanation

A. The client's symptoms of headache, blurred vision, vertigo, and nausea, even without abnormal vital signs, are suggestive of potential neurological complications from a head injury, such as increased intracranial pressure (ICP). This requires immediate attention and evaluation.
B. While the client is experiencing discomfort, it is secondary to the potential neurological issue.
C. The client's nutritional status is a concern, but it is not the priority at this time, given the potential neurological implications of the client's symptoms.
D. While the client's anxiety is understandable, it is not the primary concern given the more immediate health risk.

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Naxlex Comprehensive Predictor Exams

The nurse is evaluating the effectiveness of the incentive spirometer implemented in the client's plan of care. Which outcome statement best describes the effectiveness of the incentive spirometer?

Correct Answer is A

Explanation

Correct Answer is A

Explanation

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