An older adult patient has an intravenous infusion of 0.45% normal saline infusing at 150 mL/hr. The nurse is most concerned by which of the following assessment findings?

Tenderness at the IV site

Urine specific gravity is 1.018

Capillary refill is < 3 seconds

Newly noted crackles in the lungs

Answer and Explanation

The Correct Answer is D

A. Tenderness at the IV site: Tenderness at the IV site could indicate irritation or minor inflammation, but it is not the most concerning finding in this situation. It is a common issue with IV therapy and does not indicate a life-threatening condition.

B. Urine specific gravity is 1.018: A urine specific gravity of 1.018 is within the normal range (1.005 to 1.030), indicating adequate hydration. This is not an alarming finding in the context of IV fluid infusion.

C. Capillary refill is < 3 seconds: A capillary refill time of less than 3 seconds indicates good peripheral circulation, which is a positive sign and does not raise immediate concern regarding fluid status or complications from the IV infusion.

D. Newly noted crackles in the lungs: Crackles in the lungs can indicate fluid overload, which is a serious concern in older adults, particularly when receiving IV fluids like 0.45% normal saline. This suggests that the body is struggling to manage the fluid volume, leading to pulmonary complications.

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Correct Answer is C

Explanation

A. Pulse oximetry: Pulse oximetry measures the oxygen saturation of hemoglobin in the blood, but it does not provide information about the acid-base balance or the levels of carbon dioxide (CO2) or bicarbonate (HCO3), which are critical to understanding the acid-base status of a client.

B. Bronchoscopy: A bronchoscopy is a diagnostic procedure used to view the airways and obtain tissue samples. While it is useful in evaluating airway obstruction or lung pathology, it does not assess acid-base status.

C. Arterial blood gases (ABGs): ABGs provide the most accurate and direct measurement of acid-base balance. They assess the levels of oxygen (O2), carbon dioxide (CO2), and bicarbonate (HCO3) in the blood, and provide information on respiratory function and the body’s ability to maintain acid-base homeostasis.

D. Sputum studies: Sputum studies are helpful for diagnosing infections or analyzing secretions, but they do not provide information about the client's acid-base balance or the respiratory status regarding CO2 levels.

A. Intracellular B. Extracellular C. Intravascular D. Transcellular

Correct Answer is A

Explanation

A. Intracellular: The majority of the body's total water volume is contained within the intracellular compartment, which makes up about 2/3 total body water. Intracellular fluid is essential for cellular function, and any depletion here contributes significantly to dehydration.

B. Extracellular: While extracellular fluid (ECF) accounts for about one-third of total body water, it is not the compartment that holds the majority. ECF includes interstitial fluid, blood plasma, and lymph, but intracellular fluid still holds a larger proportion.

C. Intravascular: Intravascular fluid is a subset of extracellular fluid, specifically the fluid found within blood vessels. It makes up a smaller portion of total body water and is primarily involved in transporting nutrients and waste.

D. Transcellular: Transcellular fluid is a small compartment of extracellular fluid, including fluids such as cerebrospinal fluid, synovial fluid, and ocular fluid. It represents a very small fraction of total body water.

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An older adult patient has an intravenous infusion of 0.45% normal saline infusing at 150 mL/hr. The nurse is most concerned by which of the following assessment findings?

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