A nurse is monitoring a client who has dehydration and is receiving IV fluid replacement.
Which of the following findings should the nurse identify as effectiveness of the treatment?
Urine output 200 mL/4 hr.
Heart rate 104/min.
Peripheral pulses +1.
Urine specific gravity 1.04. .
The Correct Answer is A
Choice A rationale:
The nurse should identify that an effective outcome of IV fluid replacement in a client with dehydration is an increase in urine output. Urine output of 200 mL in 4 hours indicates that the kidneys are responding to the IV fluid replacement, and the client is likely rehydrating. This suggests that the renal perfusion has improved, and the client's body is eliminating waste products properly.
Choice B rationale:
A heart rate of 104 beats per minute is not necessarily indicative of the effectiveness of IV fluid replacement. Heart rate may vary for various reasons, and it is not a specific parameter for assessing the response to hydration. Other factors, such as blood pressure, should be considered to evaluate cardiovascular status.
Choice C rationale:
Peripheral pulses of +1 are not a direct indicator of the effectiveness of IV fluid replacement. While improved hydration may lead to better peripheral perfusion, this assessment is somewhat subjective and may not accurately reflect the overall effectiveness of the treatment.
Choice D rationale:
A urine specific gravity of 1.04 is not indicative of the effectiveness of IV fluid replacement. A specific gravity of 1.004 is within the normal range (normal range: 1.005-1.030) and does not necessarily indicate hydration status. It is essential to focus on urine output and other objective parameters to assess the effectiveness of hydration therapy. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Fine rales Fine rales, also known as crackles, are typically associated with conditions like pulmonary edema, pneumonia, or interstitial lung diseases. These sounds are often described as "crackling" or "popping" and are heard during inspiration. In an acute asthma exacerbation, expiratory wheezing is more characteristic than fine rales.
Choice B rationale:
Rhonchi Rhonchi are continuous, low-pitched sounds that can be heard in conditions like chronic obstructive pulmonary disease (COPD) or bronchitis. They are typically present during both inspiration and expiration. In an acute asthma exacerbation, you would expect to hear wheezing during expiration, which is different from the characteristics of rhonchi.
Choice D rationale:
Pleural friction rub Pleural friction rub is a grating, leathery sound caused by the inflamed pleura rubbing against each other. It is typically heard during both inspiration and expiration and is associated with conditions like pleuritis or pleurisy. It is not commonly associated with acute asthma exacerbation. Now, let's move on to the next question.
Correct Answer is A
Explanation
Choice A rationale:
The client's arterial blood gas (ABG) results indicate a low pH (acidemia) and high PaCO2, which is characteristic of respiratory acidosis. Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) from the body, leading to an accumulation of CO2 and a decrease in pH. In this case, the high PaCO2 (50 mm Hg) indicates that the client is retaining carbon dioxide, likely due to impaired ventilation. The normal pH range is 7.35 to 7.45, and the normal PaCO2 range is 35 to 45 mm Hg. These ABG values reflect an acid-base imbalance in the respiratory system, specifically, respiratory acidosis.
Choice B rationale:
Metabolic alkalosis is characterized by an elevated pH and an increase in bicarbonate (HCO3) levels. This is not the condition described in the client's ABG results, as the pH is low (acidemic) and HCO3 levels are within the normal range (24 mEq/L).
Choice C rationale:
Metabolic acidosis is characterized by a low pH and a decreased HCO3 level. The client's ABG results do not align with metabolic acidosis since the pH is low (acidemic) and the HCO3 level is within the normal range (24 mEq/L).
Choice D rationale:
Respiratory alkalosis is characterized by a high pH and low PaCO2. The client's ABG results do not match this condition as the pH is low (acidemic) and the PaCO2 is high (50 mm Hg), indicating respiratory acidosis. Therefore, choice A, respiratory acidosis, is the correct interpretation of the ABG results.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.