A nurse is caring for a client who is in labor and receiving dextrose 5% in 0.9% sodium chloride at 250 ml/hr intravenously. The client had 50 mL of urinary output in the last 4 hr. Which of the following actions should the nurse take?
Assess the client for hypoglycemia.
Administer a bolus of the IV fluid.
Assess the client's lung sounds.
Administer furosemide 10 mg PO.
The Correct Answer is C
A. Assess the client for hypoglycemia: The client is receiving dextrose-containing fluids, which help maintain blood glucose levels. Hypoglycemia is not likely the cause of decreased urine output in this context and is not the priority assessment.
B. Administer a bolus of the IV fluid: Providing a fluid bolus without first assessing fluid status may lead to fluid overload, especially if the client is already retaining fluids. This action should only follow appropriate clinical assessment.
C. Assess the client's lung sounds: Decreased urine output may signal fluid retention or early fluid overload. Assessing lung sounds is critical to detect crackles or other signs of pulmonary congestion, which can indicate complications from IV fluid administration.
D. Administer furosemide 10 mg PO: Administering a diuretic without evaluating the client's fluid balance and lung sounds can be unsafe. This decision requires a provider's order and should follow a thorough assessment of the client’s volume status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer azithromycin: Azithromycin is the antibiotic of choice for treating pertussis (whooping cough), especially in infants. Early antibiotic treatment can reduce the severity of symptoms and limit transmission of the Bordetella pertussis bacterium.
B. Initiate contact precautions: Pertussis is primarily spread via respiratory droplets, not direct contact. Therefore, droplet precautions not contact precautions are appropriate to prevent transmission to others.
C. Administer oseltamivir: Oseltamivir is an antiviral used for influenza, not for bacterial infections like pertussis. It has no therapeutic effect against Bordetella pertussis.
D. Obtain a stool culture: Pertussis is a respiratory illness and does not involve the gastrointestinal tract. Diagnostic testing would involve a nasopharyngeal swab, not stool samples.
Correct Answer is C
Explanation
A. Insert a tongue blade in the client's mouth: Forcing any object into a client’s mouth during a seizure is dangerous and can cause oral trauma or airway obstruction. It is not recommended and can worsen the situation.
B. Restrain the client's arms and legs: Restraining a client during a seizure can lead to musculoskeletal injuries. Instead, the nurse should allow spontaneous movement and focus on protecting the client from harm.
C. Place the client on her side: Turning the client to the side helps maintain a patent airway and allows saliva or vomit to drain, reducing the risk of aspiration. It is a priority action during seizure management.
D. Raise the client's bed to the high position: Raising the bed increases the risk of injury from falls or uncoordinated movements during or after the seizure. The bed should be in a low position with padded side rails if necessary.
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