A nurse is admitting a client who reports persistent nausea, vomiting, and weakness for three days. The client has dry oral mucous membranes, weak peripheral pulses, and decreased skin turgor. What additional assessment findings should the nurse identify as manifestations related to the fluid imbalance? (Select All That Apply)

Muscle cramps

Bradycardia

Concentrated urine

Tachycardia

Increased thirst

Answer and Explanation

Correct Answer : A,C,D,E

A. Muscle cramps: Muscle cramps can occur due to electrolyte imbalances, such as low potassium, which are common in states of dehydration and fluid imbalance.
B. Bradycardia: Bradycardia is not typically associated with dehydration or fluid imbalance. Dehydration usually causes an increase in heart rate (tachycardia) as the body tries to maintain adequate circulation.
C. Concentrated urine: Concentrated urine is a common sign of dehydration as the kidneys conserve water, leading to reduced urine output and higher urine concentration.
D. Tachycardia: Tachycardia is a compensatory mechanism in response to decreased fluid volume, as the heart pumps faster to maintain adequate blood flow and blood pressure.
E. Increased thirst: Increased thirst is a natural response to dehydration as the body signals the need for more fluid intake to correct the fluid imbalance.

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Correct Answer is B

Explanation

A. Start an IV of DSNS with 40 mEq KCI at 125 mL/hr: Starting an IV is important but may not be the immediate first step. The client's symptoms suggest hypotension, likely due to hypovolemia, which needs immediate positional intervention before fluid administration.
B. Elevate the feet and lower the head: This position, known as the Trendelenburg position, helps increase venous return to the heart and can quickly improve blood pressure and perfusion to vital organs. It is an immediate intervention for hypotension.
C. Call the surgeon and report the vital signs: While important, calling the surgeon is not the first intervention. Immediate action to stabilize the client's condition is necessary before notifying the healthcare provider.
D. Monitor the vital signs every 15 minutes: Monitoring is important, but it is not an immediate intervention. The nurse must first address the client's low blood pressure and symptoms of hypoperfusion before continuing regular monitoring.

A. Decrease the TPN rate to 60 ml/hr B. Replace TPN infusion with an intravenous dextrose solution C. Begin infusion of 0.9% normal saline at 30 ml/hr D. Discontinue TPN infusion E. Discontinue TPN infusion

Correct Answer is B

Explanation

A. Decrease the TPN rate to 60 ml/hr: Gradually decreasing the TPN rate is a common practice, but it is typically done in conjunction with transitioning to another form of nutrition, not as a standalone order.
B. Replace TPN infusion with an intravenous dextrose solution: This is the correct choice. When weaning off TPN, it is important to prevent hypoglycemia by replacing the TPN with a dextrose solution to maintain blood glucose levels while transitioning to oral or enteral feeding.
C. Begin infusion of 0.9% normal saline at 30 ml/hr: While saline may be used for hydration, it does not address the need to manage blood glucose levels during the transition from TPN.
D. Discontinue TPN infusion: Discontinuing TPN abruptly can lead to complications such as hypoglycemia. It is important to gradually taper off TPN while replacing it with a dextrose solution.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client in the post-anesthesia care unit. The client's vital signs are T 98°F, P 106, R 24, and BP 88/40. The client is awake and oriented x 3 and the skin is pale and damp. The client denies complaints of pain. What intervention should the nurse implement first?

Correct Answer is B

Explanation

Orders were written for a client to be weaned off of total parenteral nutrition (TPN) and started on a low-residue diet. The TPN solution has been infusing at a continuous rate of 90 ml/hr for three weeks. Which of the following orders should the nurse anticipate next?

Correct Answer is B

Explanation

Which of the following assessment findings should alert the nurse that a client's IV has infiltrated? (Select All That Apply)

A client who takes furosemide (Lasix) and propranolol (Inderal) is scheduled for breast reconstruction surgery. Which additional client information requires prompt collaboration with the healthcare provider before surgery?

The nurse is educating a group of student nurses about the different types of anesthesia. The student demonstrates an understanding of the teaching when they state that a client would maintain a gag reflex with what anesthesia?

The nurse is caring for a client being treated for fluid volume excess. Which assessment finding indicates that treatment has been effective?

A nurse is monitoring a client who is receiving IV fluid. Which clinical findings indicate that the client has fluid overload?

The nurse is taking a medication history of a client scheduled for surgery the next morning. Which medication requires the nurse to immediately notify the surgeon?