A nurse is caring for a client.

Vital Signs Nurses Notes 1000:

T38.2° C (100.8°F), oral.

BP 114/56 mm Hg, supine HR 99/min

R 32/min

Pulse oximetry 85% on room air (95% to 100%)

1100:

T38.6° C (101.5°F), oral.

BP 112/54 mm Hg, supine Apical HR 108/min

Pulse oximetry 90% on 40% O2 via face mask

Pink mucous membrane is a normal finding.

R 22/min

Click to highlight the findings at 1100, that require follow-up. To deselect a finding, click on the finding again.

T38.6° C (101.5°F), oral.

BP 112/54 mm Hg, supine

Apical HR 108/min

R 22/min

Pulse oximetry 90% on 40% O2 via face mask

Pink mucous membrane is a normal finding.

Answer and Explanation

The Correct Answer is ["A","C","E"]

A.   Elevated oral temperature may indicate a fever and requires further assessment.
B.   This blood pressure value is within the normal range.
C.   An elevated heart rate (108/min) suggests tachycardia, and it requires further investigation to determine the cause.
D.   A respiratory rate of 22/min is not a finding that raises concern.
E.   A pulse oximetry reading of 90% on supplemental oxygen (40% O2) is below the expected range, indicating potential respiratory distress and requiring immediate attention.
F.   Pink mucous membrane is a normal finding.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Hypokalemia can be caused by excessive loss of potassium from the gastrointestinal tract, such as from vomiting, diarrhea, or gastric suction.
B. Drinking a large amount of water is more likely to dilute sodium levels rather than potassium.
C. Alcohol abuse disorder is not a direct cause of low potassium levels.
D. Spironolactone is a potassium-sparing diuretic, and its use can lead to hyperkalemia, not hypokalemia.

Correct Answer is ["125"]

Explanation

Identify the given values:
- Total volume = 1000 mL
- Total infusion time = 8 hours
Use the formula for infusion rate:

Infusion Rate (mL/hr) = Total Volume (mL) ÷ Total Time (hours)

Infusion Rate = 1000 mL ÷ 8 hours

Infusion Rate = 125 mL/hr

Final Answer:

The nurse should set the IV pump to 125 mL/hr for the 0.45% NaCl solution

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

Correct Answer is A

Explanation

A nurse is preparing to administer 0.45% sodium chloride (NaCl) 1000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

Correct Answer is ["125"]

Explanation

A nurse is preparing to administer 40 mEq of potassium chloride in 45% sodium chloride (NaCl) 500 mL IV to infuse 10 mEq/hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

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