A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

Slow infusion rate and contact the provider.

Lower the head of the bed to semi-Fowler's.

Administer prescribed corticosteroids.

Change infusion to lactated Ringer's and maintain rate.

Answer and Explanation

The Correct Answer is A

A.   The client's dyspnea and elevated blood pressure may indicate fluid volume overload. Slowing the infusion rate and notifying the provider are appropriate actions.
B.   Lowering the head of the bed may help with dyspnea but does not address the underlying cause of fluid overload.
C.   Administering corticosteroids is not indicated based on the client's symptoms and situation.
D.   Changing the infusion to lactated Ringer's may be appropriate, but slowing the infusion rate and assessing the client further are the priority actions.

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Correct Answer is ["69"]

Explanation

To calculate the daily protein requirement for the client, first convert the weight from pounds to kilograms, knowing that 1 kilogram equals 2.2 pounds.

The client's weight in kilograms is 190 lb divided by 2.2, which equals approximately

86.36 kg.

Then, multiply the weight in kilograms by the recommended dietary allowance (RDA) of protein, which is 0.8 g/kg. So, 86.36 kg multiplied by 0.8 g/kg equals about

69.09 g. Rounding to the nearest whole number, the client should receive 69 grams of protein daily.

A. Keep the client's knees in a flexed position while they are in bed. B. Massage the client's legs every 4 hr while they are awake. C. Encourage the client to perform circumduction of the feet. D. Limit the client's fluid intake to 2,000 mL daily.

Correct Answer is C

Explanation

A) Keeping the client's knees in a flexed position, is incorrect because prolonged immobility and knee flexion can increase the risk of VTE by impeding venous return.
B) Massaging the client's legs, is not recommended as it may dislodge a potential clot that has formed, leading to a thromboembolic event.
C) This exercise can help promote blood circulation and prevent clot formation without exerting excessive pressure on the surgical site.
D) Adequate hydration is essential for preventing blood clots; dehydration can lead to hemoconcentration and increased risk of thrombosis.

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A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg. a fluid intake of 960 mL, and an output of 300 mL in the past 12 hr. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["69"]

Explanation

A nurse is caring for a client who is 3 hr postoperative following a total knee arthroplasty. Which of the following actions should the nurse take to prevent venous thromboembolism?

Correct Answer is C

Explanation

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