Exhibits
Given the client's current treatment for fluid volume deficit, what condition(s) should the practical nurse (PN) monitor the client for? Select all that apply.
Thrombocytopenia
Pulmonary edema
Hypokalemia
Alkalosis
Phlebitis
Hyponatremia
Diarrhea and vomiting
Hyperglycemia
Correct Answer : B,C,E
A. Thrombocytopenia
Monitoring for thrombocytopenia is not directly related to the treatment of fluid volume deficit. While it is important to watch for any blood-related issues, thrombocytopenia is not a common concern specifically due to the administration of isotonic fluids like 0.9% sodium chloride. This condition would not be a primary focus in this scenario.
B. Pulmonary edema
The client should be monitored for pulmonary edema as a potential complication of fluid resuscitation. Administering large volumes of isotonic fluids can lead to fluid overload, which may cause pulmonary edema. This is especially important given the presence of pneumonia and the client's symptoms of shortness of breath and crackles in the lung fields.
C. Hypokalemia
Hypokalemia should be monitored as a potential complication of isotonic fluid administration. Although 0.9% sodium chloride does not contain potassium, patients receiving IV fluids for a significant period may develop electrolyte imbalances, including hypokalemia. Monitoring serum electrolytes is necessary to address such imbalances.
D. Alkalosis
Alkalosis is less likely to occur with isotonic fluids like 0.9% sodium chloride. This type of fluid generally does not cause acid-base imbalances such as alkalosis. The treatment for fluid volume deficit is not expected to lead to alkalosis, which is more commonly associated with metabolic alkalosis from other sources.
E. Phlebitis
Phlebitis should be monitored due to the presence of a peripheral IV access device. Long-term or large-volume infusions can irritate the vein, leading to inflammation or phlebitis. Regular inspection of the IV site for redness, swelling, or pain is necessary to prevent and manage this complication.
F. Hyponatremia
Hyponatremia is not a direct concern with isotonic fluids like 0.9% sodium chloride, as these fluids maintain sodium levels without causing a dilution effect. Monitoring sodium levels is generally more relevant in cases where hypotonic fluids are used.
G. Diarrhea and vomiting
Diarrhea and vomiting are not directly related to isotonic fluid administration. Although these symptoms can contribute to fluid volume deficits, they are not a common complication of fluid resuscitation.
H. Hyperglycemia
Hyperglycemia is not a concern with isotonic fluids like 0.9% sodium chloride. Hyperglycemia is more associated with fluids containing glucose, such as dextrose solutions. Therefore, monitoring for hyperglycemia is not necessary in this context
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.6"]
Explanation
- Medication dose: 30 mg enoxaparin
- Medication concentration: 30 mg per 0.3 mL (prefilled syringe)
- Frequency: Every 12 hours
- Duration: 10 days
Calculation:
- Injections per day: Since the medication is given every 12 hours, the client will receive injections 2 times per day (24 hours / 12 hours/injection).
- Total medication per day: To find the total amount of enoxaparin needed per day, multiply the single injection dose by the number of injections:
Total enoxaparin/day = Dose per injection x Number of injections/day = 30 mg/injection x 2 injections/day = 60 mg/day
- Volume of medication per day: Now, we need to find the volume of solution needed to deliver the total daily dose (60 mg) based on the medication concentration (30 mg/0.3 mL). We can achieve this with a proportion:
Volume (mL) / Total dose (mg) = Concentration (mg/mL)
Volume (mL) = (Total dose (mg) x Concentration (mL/mg)) / Concentration (mg/mL)
Plugging in the values:
Volume (mL) = (60 mg x 0.3 mL/mg) / 30 mg/mL
Volume (mL) = 18 mL / 30 mL/mL
Simplifying:
Volume (mL) = 0.6 mL
Therefore, the practical nurse (PN) should administer 0.6 mL of enoxaparin each day.
Correct Answer is B
Explanation
A. Elevated blood glucose is not typically associated with Cheyne-Stokes respirations. It might indicate diabetes or hyperglycemia but does not relate to this specific pattern of breathing.
B. Cheyne-Stokes respirations are often observed when death is imminent or in severe cases of terminal illness. This breathing pattern is characterized by cycles of increasing and decreasing respirations, often seen in end-of-life care.
C. An allergic reaction might cause respiratory symptoms, but it is not specifically associated with Cheyne-Stokes respirations. Assessing for Cheyne-Stokes would be more relevant in terminal or serious conditions rather than acute allergic reactions.
D. Cheyne-Stokes respirations are not related to strenuous exercise. After exercise, normal changes in breathing patterns occur, but Cheyne-Stokes respirations are indicative of more severe conditions.
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