The nurse is assessing a patient and finds crackles in the lung bases and neck vein distention. Which action will the nurse take first?
Offer calcium-rich foods.
Administer diuretic.
Raise head of bed.
Increase fluids.
The Correct Answer is C
A. Offer calcium-rich foods: While calcium is important for overall health, offering calcium-rich foods is not an immediate intervention for the symptoms of crackles and neck vein distention. These signs suggest fluid overload, which needs urgent management.
B. Administer diuretic: Administering a diuretic can help remove excess fluid, but the first priority is to ensure the patient’s airway and breathing are supported. Diuretics can be administered once the patient is positioned properly.
C. Raise head of bed: Raising the head of the bed improves ventilation and helps alleviate respiratory distress, which is crucial when crackles, indicative of fluid in the lungs, and neck vein distention, suggesting fluid overload are present. This will help reduce the work of breathing and ease the patient’s discomfort.
D. Increase fluids: Increasing fluids is not appropriate in this situation because the patient is showing signs of fluid overload, crackles and neck vein distention. Fluid restriction or removal is required, not additional fluid intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. High: The relationship between calcium and phosphate is inverse, meaning when calcium levels rise, phosphate levels tend to decrease, and vice versa. Therefore, the phosphate level would not be expected to be high if the calcium level is within the normal range.
B. The same as the calcium level: While calcium and phosphate levels are related, they do not typically mirror each other directly. They have an inverse relationship, not a one-to-one correlation.
C. Low: Since calcium and phosphate have an inverse relationship, a normal calcium level generally indicates that phosphate levels are also normal, not necessarily low.
D. Normal: With a calcium level of 9.5 mg/dL, which is within the normal range, it is expected that the phosphate level would also be within the normal range, as long as there are no other underlying conditions affecting these levels.
Correct Answer is ["44"]
Explanation
Calculation:
- Convert the infusion rate from milliliters per hour (mL/hr) to milliliters per minute (mL/min).
Infusion rate in mL/min = 175 mL/hr / 60 min/hr
= 2.9166... mL/min.
Tubing drop factor = 15 gtt/mL.
- Calculate the flow rate in drops per minute (gtt/min).
Flow rate (gtt/min) = Infusion rate (mL/min) × Tubing drop factor (gtt/mL)
= 2.9166... mL/min × 15 gtt/mL
= 43.75 gtt/min.
- Round the answer to the nearest whole number.
= 44 gtt/min.
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.
