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 B

Explanation

A. Client taking furosemide (Lasix): Furosemide is a diuretic that primarily affects urine volume and does not directly increase insensible water loss. Insensible water loss refers to water lost through skin and respiratory routes, not through urination.

B. Anxious client who has tachypnea: Tachypnea, or rapid breathing, increases the rate of water loss through the respiratory system (insensible water loss). When breathing rapidly, the body loses more moisture in the form of vapor, making this client at greatest risk.

C. Client who is on fluid restrictions: Although fluid restrictions limit overall intake, this does not increase the risk for insensible water loss, which occurs primarily through skin and respiratory loss. Fluid restriction impacts overall fluid balance rather than insensible losses.

D. Client who is constipated with abdominal pain: Constipation and abdominal pain may contribute to some discomfort or difficulty with fluid intake, but they are not related to increased insensible water loss.

A. Repeatedly asking "Where am I?" B. Difficult to arouse C. Barrel chest D. Dysrhythmias E. Rapid, shallow respirations

Correct Answer is ["A","B","D"]

Explanation

A. Repeatedly asking "Where am I?": This can be a sign of confusion or disorientation due to the buildup of CO2 in respiratory acidosis. As CO2 accumulates in the blood, it can lead to impaired brain function, resulting in confusion or altered mental status.

B. Difficult to arouse: Respiratory acidosis leads to increased CO2 levels, which can depress the central nervous system, causing lethargy and difficulty arousing the patient. This is a common manifestation of respiratory acidosis, especially in severe cases.

C. Barrel chest: A barrel chest is a long-term, chronic structural change in the chest wall, commonly seen in individuals with advanced COPD. While a client with COPD will likely have a barrel chest, it is a chronic anatomical finding, not an acute clinical sign resulting from current respiratory acidosis.

D. Dysrhythmias: Elevated CO2 levels can affect the heart's electrical conduction system, leading to arrhythmias. This is a known complication of respiratory acidosis, particularly in COPD patients, as the body struggles to compensate for the acidotic state.

E. Rapid, shallow respirations: Rapid, shallow respirations are more typical of respiratory alkalosis, where the body is trying to expel CO2 quickly. In respiratory acidosis, the body may attempt to compensate by increasing the rate of breathing, but the respirations are typically deep and labored (Kussmaul's respirations), not shallow.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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Correct Answer is ["A","B","D"]

Explanation

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