A nurse is caring for a client who has an NG tube to suction and is receiving IV fluids to maintain fluid volume balance. Which of the following findings should indicate to the nurse that this therapy is effective?
Decreased NG tube drainage.
Potassium 3.3 mEq/L.
Increased heart rate.
Hematocrit 46%.
The Correct Answer is A
Choice A rationale:
A decrease in NG tube drainage indicates that the client's stomach contents are not being aspirated excessively, which suggests that the IV fluids are effectively maintaining fluid volume balance. This finding is positive because it shows that the client is retaining the fluids they need, and it may also indicate improved gastrointestinal function and decreased risk of dehydration.
Choice B rationale:
The potassium level of 3.3 mEq/L (milliequivalents per liter) is low. The normal range for potassium is typically between 3.5 to 5.0 mEq/L. Hypokalemia (low potassium) can result from various factors and may cause muscle weakness, cardiac arrhythmias, and other complications. It is not a finding that indicates the effectiveness of fluid volume balance therapy.
Choice C rationale:
An increased heart rate may suggest that the client is experiencing fluid volume deficit or other physiological stress. It is not a finding that indicates the effectiveness of fluid volume balance therapy.
Choice D rationale:
A hematocrit level of 46% is within the normal range for adult males (typically around 38.8% to 50%) and indicates the proportion of red blood cells in the blood. While it can provide information about blood viscosity and hydration status, it does not directly indicate the effectiveness of fluid volume balance therapy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse's first priority in this situation should be to close the pinch clamp on the central venous catheter (CVC). This will prevent air from entering the client's vascular system and causing an air embolism, which can lead to serious complications. Once the clamp is closed, the nurse can then proceed with further assessments and interventions.
Choice B rationale:
Obtaining a prescription for stat ABGS (Arterial Blood Gas Studies) is not the first action the nurse should take in this situation. While ABGS may be relevant later to assess the client's respiratory status, the immediate concern is to prevent air embolism by closing the disconnected IV tubing.
Choice C rationale:
Placing the client in the left Trendelenburg position is not the first priority in this situation. The Trendelenburg position is used to increase venous return and is typically indicated in cases of hypotension or shock. Closing the clamp to prevent an air embolism should be the nurse's initial action.
Choice D rationale:
Checking the tubing for the placement of a locking adaptor is not the first action the nurse should take. While it is essential to ensure that the IV tubing is properly connected and secured, preventing the air from entering the CVC should take precedence in this urgent situation.
Correct Answer is D
Explanation
Choice A rationale:
Fruity-smelling breath is associated with diabetic ketoacidosis (DKA), which is not the expected manifestation of chronic kidney disease (CKD). DKA occurs in uncontrolled diabetes and is not the priority for this client.
Choice B rationale:
Painful urination is not a typical clinical manifestation of chronic kidney disease. It is more commonly associated with urinary tract infections or other urological issues.
Choice C rationale:
Hypotension may occur in end-stage kidney disease, but it is not specific to chronic kidney disease and is not a priority in this scenario.
Choice D rationale:
Lethargy is a common clinical manifestation of chronic kidney disease due to the accumulation of waste products in the blood, leading to uremia. It is a priority as it indicates the progression of the disease and the need for close monitoring and intervention.
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