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 C
Explanation
Choice A rationale:
A blood glucose level of 100 mg/dL is within the normal range, so there is no need to notify the provider of this finding.
Choice B rationale:
A client's temperature of 37.6°C (99.7°F) is slightly elevated but not considered a critical finding. It may be indicative of an infection or other mild inflammation, but it does not warrant immediate provider notification.
Choice C rationale:
A potassium level of 5.7 mEq/L is above the normal range (3.5-5.0 mEq/L). Hyperkalemia can lead to serious cardiac complications, such as arrhythmias, and requires immediate attention from the provider.
Choice D rationale:
Weight loss of 0.8 kg/day (1.8 lb/day) should be evaluated and monitored, but it is not an immediate concern that warrants urgent provider notification.
Correct Answer is C
Explanation
Choice A rationale:
Increasing the intake of high-fiber foods is not relevant to managing dry mouth caused by benztropine. While fiber is essential for digestive health, it does not directly address the issue of dry mouth.
Choice B rationale:
Chewing sugarless gum can be helpful in promoting saliva production, but in Parkinson's disease, it can exacerbate swallowing difficulties and increase the risk of aspiration.
Choice C rationale:
Moistening the mouth with lemon-glycerin swabs is the appropriate recommendation. Lemon-glycerin swabs can help lubricate the mouth and provide relief from dryness, which is a common side effect of benztropine, an anticholinergic medication.
Choice D rationale:
Rinsing the mouth with nystatin is used to treat oral candidiasis (thrush), a fungal infection, and is not relevant to managing dry mouth caused by benztropine.
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