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 C
Explanation
A. Increased glucose level: CSF glucose levels are typically normal in multiple sclerosis. An increase in glucose is more commonly associated with systemic hyperglycemia or specific infections, not demyelinating diseases like MS.
B. Decreased lactic acid level: A decreased lactic acid level is not a characteristic finding in multiple sclerosis. Lactic acid in CSF is more relevant in differentiating types of infections, such as bacterial versus viral meningitis.
C. Increased protein level: Elevated protein in the CSF is a common finding in multiple sclerosis, often due to increased immunoglobulin production and the presence of oligoclonal bands, reflecting immune system activity in the CNS.
D. Decreased WBC count: While a mild increase in WBC count may be seen in MS, a decreased WBC count is not typical or diagnostic of the disease. Leukocyte levels in CSF are usually normal or slightly elevated in MS.
Correct Answer is B
Explanation
A. "I will remove the yellow exudate that forms around his penis." The yellow exudate is part of normal healing and should not be removed. Disturbing this layer can delay healing and increase the risk of bleeding or infection.
B. "I will apply petrolatum to his penis with each diaper change." Applying petrolatum helps prevent the diaper from sticking to the healing circumcision site, reducing discomfort and protecting the wound from friction and contamination during diaper changes.
C. "I will change his diaper every 6 hours." Diapers should be changed more frequently, especially after each bowel movement or urination, to keep the area clean and dry and reduce the risk of infection at the circumcision site.
D. "I will ensure that the diaper is firmly applied to the circumcised area." The diaper should be applied snugly but not firmly or tightly. Excess pressure on the circumcised area can cause pain or impair circulation, delaying healing.
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