The nurse is caring for a client who is admitted with acute dehydration and a serum sodium level of 151mEq/L. The nurse is anticipating the administration of DSW based on which of the following principles?

This fluid is most compatible with antibiotics

This fluid acts as free water to help dilute the sodium.

This fluid contains higher than normal amounts of sodium.

This fluid is used to pull water out of the interstitial space.

Answer and Explanation

The Correct Answer is B

A. DSW (Dextrose in water) is not specifically used for compatibility with antibiotics. It is an intravenous fluid that provides water and glucose, but its use is not based on antibiotic compatibility.
B. DSW (5% dextrose in water) provides free water to the body. In the case of acute dehydration and hypernatremia, the water helps to dilute the high sodium levels in the bloodstream, lowering the sodium concentration.
C. DSW does not contain higher-than-normal amounts of sodium. It contains only a small amount of sodium from the dextrose, and its primary role is to provide free water.
D. DSW is not used to pull water out of the interstitial space. Hypertonic solutions (like 3% saline) are used for that purpose, not DSW.

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Correct Answer is C

Explanation

A. Decreasing fluid intake can actually increase the risk of urinary tract infections (UTIs) because it leads to concentrated urine and less frequent urination, which reduces the ability to flush bacteria from the urinary tract.
B. Cleansing the perineal area from back to front increases the risk of transferring bacteria from the rectum to the urethra, which is a common cause of UTIs. The correct technique is to cleanse from front to back.
C. Utilizing cotton rather than synthetic undergarments is beneficial because cotton is breathable and helps keep the genital area dry, reducing the risk of bacterial growth and infection.
D. Urinary tract infections are unavoidable in the elderly is not true. While the elderly may be at increased risk due to factors such as weakened immune systems, UTIs can often be prevented with proper hygiene, hydration, and lifestyle changes.

A. An area of non-blanchable redness on intact skin.. B. An area of shallow broken skin with blistering C. Deep purple discoloration over intact skin D. An open wound with visible adipose tissue and eschar.

Correct Answer is B

Explanation

A. An area of non-blanchable redness on intact skin is characteristic of a stage I pressure injury, not stage II. In stage I, the skin remains intact but shows redness that does not blanch when pressed.
B. An area of shallow broken skin with blistering describes a stage II pressure injury. Stage II involves partial-thickness loss of skin, which may present as a blister or shallow open ulcer, often with a pink or red wound bed.
C. Deep purple discoloration over intact skin refers to a suspected deep tissue injury, which is a different classification of pressure injury. It indicates damage to underlying tissue but does not involve a break in the skin.
D. An open wound with visible adipose tissue and eschar is indicative of a stage III pressure injury, which involves full-thickness skin loss and may expose underlying structures like fat, but not bone or muscle (which would indicate stage IV). Stage III wounds may also have eschar or slough, but stage II wounds do not.

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The nurse is caring for a client who is admitted with acute dehydration and a serum sodium level of 151mEq/L. The nurse is anticipating the administration of DSW based on which of the following principles?

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