Instructions:
Use this scenario for the next 4 questions.
Indicate which assessment findings correlate with the nursing problem you identified. (Select all that apply)
Watery diarrhea for 3 days.
Chronic kidney disease, which has been managed with diuretics and fluid restrictions.
Lung sounds are clear.
No nausea and vomiting.
History of hypertension.
Blood urea nitrogen (BUN).
Correct Answer : A,B,E,F
Choice A reason:
Watery diarrhea for 3 days is a significant finding that correlates with fluid and electrolyte imbalances. Diarrhea leads to the loss of fluids and electrolytes, which can result in dehydration and electrolyte disturbances such as hypokalemia or hyperkalemia. In this case, the patient’s potassium level is elevated (5.6 mEq/L), which could be a result of the body’s attempt to compensate for the loss of other electrolytes. Diarrhea also contributes to the patient’s weakness and lightheadedness due to dehydration.
Choice B reason:
Chronic kidney disease, which has been managed with diuretics and fluid restrictions, is another critical factor. Chronic kidney disease (CKD) affects the body’s ability to regulate fluid and electrolytes. The use of diuretics can exacerbate electrolyte imbalances, particularly potassium levels. In this scenario, the patient’s elevated potassium level (5.6 mEq/L) is concerning, as CKD patients are at higher risk for hyperkalemia due to decreased renal excretion of potassium. The combination of CKD and recent diarrhea increases the complexity of managing the patient’s fluid and electrolyte balance.
Choice C reason:
Lung sounds are clear is an important assessment finding but does not directly correlate with the primary nursing problem of fluid and electrolyte imbalance. While clear lung sounds indicate that the patient is not experiencing respiratory complications such as pulmonary edema or infection, this finding does not address the immediate concerns related to fluid loss and electrolyte disturbances. Therefore, it is not a priority in this context.
Choice D reason:
No nausea and vomiting is a relevant finding but does not directly correlate with the primary nursing problem. The absence of nausea and vomiting is positive, as it indicates that the patient is not losing additional fluids and electrolytes through emesis. However, it does not address the significant fluid loss from diarrhea or the electrolyte imbalances that are the primary concerns in this scenario.
Choice E reason:
History of hypertension is a relevant factor in the patient’s overall health status. Hypertension can complicate the management of fluid and electrolyte imbalances, particularly in patients with CKD. The use of antihypertensive medications and diuretics can affect electrolyte levels and fluid balance. In this case, the patient’s blood pressure is slightly low (109/70), which could be related to dehydration from diarrhea and the effects of antihypertensive medications. This history is important for understanding the patient’s baseline and potential complications.
Choice F reason:
Blood urea nitrogen (BUN) is elevated at 30 mg/dL, which is above the normal range (6-24 mg/dL). An elevated BUN level indicates impaired kidney function and can be a sign of dehydration or renal insufficiency. In the context of CKD and recent diarrhea, an elevated BUN suggests that the kidneys are struggling to manage the body’s waste products and fluid balance. This finding is critical for understanding the extent of the patient’s fluid and electrolyte imbalances and guiding appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Peripheral pulses
Monitoring peripheral pulses is important for assessing circulation and detecting any signs of vascular complications. However, it is not the most critical assessment for a patient receiving 3% NaCl for hyponatremia. The primary concern with hypertonic saline infusion is the risk of fluid overload and central nervous system (CNS) complications.
Choice B: Urinary output
Monitoring urinary output is essential for assessing kidney function and fluid balance. While it is important, it is not the most critical assessment in this scenario. The primary risks associated with 3% NaCl infusion include rapid changes in serum sodium levels and potential CNS complications.
Choice C: Peripheral edema
Peripheral edema can indicate fluid overload, but it is not the most immediate concern when administering hypertonic saline. The nurse should prioritize monitoring for signs of pulmonary edema and neurological changes, which can occur more rapidly and have more severe consequences.
Choice D: Lung sounds and neurological status
Monitoring lung sounds and neurological status is the most important assessment for a patient receiving 3% NaCl for hyponatremia. Hypertonic saline can cause rapid shifts in fluid balance, leading to pulmonary edema and neurological complications such as osmotic demyelination syndrome. Assessing lung sounds helps detect early signs of fluid overload in the lungs, while monitoring neurological status helps identify any changes in mental status or neurological function that could indicate serious complications.
Correct Answer is C
Explanation
Choice A: Demonstrate a caring attitude to the patient and family
While demonstrating a caring attitude is an essential aspect of nursing, it is not the primary goal of pain assessment. A caring attitude helps build trust and rapport with patients and their families, which is crucial for effective communication and overall patient care. However, the main objective of pain assessment is to gather data that will inform pain management strategies.
Choice B: Ensure complete documentation in the EHR
Ensuring complete documentation in the Electronic Health Record (EHR) is important for maintaining accurate patient records and facilitating communication among healthcare providers. However, this is a secondary goal that supports the primary objective of pain assessment. The main focus of pain assessment is to collect data that will guide pain management interventions.
Choice C: Gather subjective and objective data in order to plan and implement appropriate pain management techniques
This is the correct answer. The primary goal of a nursing pain assessment is to gather both subjective data (patient’s self-reported pain levels, descriptions, and experiences) and objective data (observations, vital signs, and physical assessments). This comprehensive data collection allows nurses to develop and implement effective pain management plans tailored to the individual needs of the patient. Accurate pain assessment is crucial for identifying the type, intensity, and cause of pain, which in turn informs the selection of appropriate pain relief measures.
Choice D: Develop a therapeutic relationship with the patient
Developing a therapeutic relationship with the patient is an important aspect of nursing care, as it fosters trust and open communication. However, it is not the primary goal of pain assessment. The main objective of pain assessment is to gather data that will inform pain management strategies. A therapeutic relationship can enhance the effectiveness of pain assessment and management, but it is a means to an end rather than the end itself.
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