A nurse is caring for a client who has suffered acute blood loss and is experiencing hypovolemia due to third-space fluid shifts.
The physician orders Lactated Ringer’s solution for fluid resuscitation.
The nurse knows that this solution contains Sodium 130 mEq/L, Chloride 109 mEq/L, Potassium 4 mEq/L, Calcium 3 mEq/L, and Lactate 28 mEq/L.
Which of the following statements are true regarding Lactated Ringer’s solution? (Select all that apply).
Lactated Ringer’s solution is contraindicated in cases of hyperkalemia.
Lactated Ringer’s solution is contraindicated in cases of hypokalemia.
Lactated Ringer’s solution can be used in cases of lower GI fluid loss.
Lactated Ringer’s solution can be used in cases of upper GI fluid loss.
Lactated Ringer’s solution is contraindicated in cases of lactic acidosis.
Correct Answer : B,C,D
Choice A rationale:
Lactated Ringer's solution is not contraindicated in cases of hyperkalemia.
This solution contains potassium in a relatively low concentration of 4 mEq/L, which is unlikely to significantly impact hyperkalemia.
Choice B rationale:
Lactated Ringer's solution can be contraindicated in cases of hypokalemia.
While it does contain potassium, the concentration is relatively low at 4 mEq/L.
In cases of severe hypokalemia, a more potassium-rich solution might be preferred.
Choice C rationale:
Lactated Ringer's solution can be used in cases of lower GI fluid loss.
It can help replace lost fluids and electrolytes effectively.
Choice D rationale:
Lactated Ringer's solution can be used in cases of upper GI fluid loss.
It helps restore lost fluids and electrolytes.
Choice E rationale:
Lactated Ringer's solution is not contraindicated in cases of lactic acidosis.
In fact, it contains lactate (28 mEq/L), which can be metabolized to bicarbonate and help correct acidosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
"The child's favorite foods and beverages" are not relevant when assessing dehydration.
While dietary habits are essential for overall health, they do not provide information about the child's hydration status.
Choice B rationale:
"The child's school attendance and activities" are unrelated to the assessment of dehydration.
School attendance and activities are important for a child's social and educational development but do not provide any insight into the child's fluid balance or hydration status.
Choice C rationale:
"The child's skin turgor and mucous membranes" are crucial indicators of dehydration during physical examination.
Poor skin turgor, where the skin tents or remains elevated after being pinched, suggests decreased tissue elasticity due to fluid loss.
Dry mucous membranes, including the mouth, indicate dehydration.
These signs provide immediate visual clues about the child's hydration status and guide further assessment and intervention.
Choice D rationale:
"The child's vaccination history" is not relevant to the assessment of dehydration.
While vaccination history is essential for preventive healthcare, it does not provide any information about the child's current hydration status or fluid balance.
Correct Answer is B
Explanation
Choice A rationale:
"Height and weight.”.
Rationale: While monitoring height and weight is important for a child's growth and development, these parameters are not the primary vital signs to assess dehydration.
Dehydration assessment focuses on immediate physiological indicators, such as heart rate and blood pressure.
Choice B rationale:
"Heart rate and blood pressure.”.
Rationale: This is The correct answer.
When assessing a dehydrated child, monitoring vital signs such as heart rate and blood pressure is crucial.
Dehydration can lead to an increased heart rate and decreased blood pressure.
These parameters provide valuable information about the child's circulatory status and fluid balance.
Choice C rationale:
"Hair and eye color.”.
Rationale: Hair and eye color are not relevant parameters for assessing dehydration.
They are genetic traits and do not change in response to dehydration.
Choice D rationale:
"Shoe size and clothing size.”.
Rationale: Shoe size and clothing size are not relevant for assessing dehydration.
These measurements are related to a child's growth and body structure but do not provide information about their hydration status.
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