The picture below is an assessment finding of a nurse. What nursing intervention will the nurse expect to do?
Administer a bolus of 0.9% Normal Saline per physician order
Administer a bolus of 3% Normal Saline per physician order
Walk the patient down the hallway 10 feet
Turn the patient every two hours
The Correct Answer is A
A. Administer a bolus of 0.9% Normal Saline per physician order: The image shows poor skin turgor, a classic sign of dehydration. Skin that “tents” when pinched indicates fluid volume deficit, requiring isotonic fluid replacement such as 0.9% normal saline to restore intravascular volume.
B. Administer a bolus of 3% Normal Saline per physician order: 3% Normal Saline is hypertonic and reserved for severe hyponatremia or cerebral edema. It is not appropriate for general dehydration and can cause fluid shifts leading to complications if misused.
C. Walk the patient down the hallway 10 feet: Ambulating a dehydrated or volume-depleted patient could worsen hypotension or dizziness, risking falls. Hydration should precede mobility in such cases.
D. Turn the patient every two hours: Repositioning every 2 hours is important for pressure injury prevention but does not address the underlying issue of dehydration evident in the assessment finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
A. Foot drop: Foot drop occurs when a person is unable to lift the front part of the foot due to weakness or paralysis of the muscles in the lower leg. Prolonged immobility can lead to contractures and muscle atrophy, increasing the risk of foot drop as the muscles weaken over time.
B. Orthostatic Hypotension: Orthostatic hypotension is a common complication of prolonged bedrest. The lack of movement and the reduced ability to adjust blood pressure upon standing can lead to dizziness, fainting, or falls in immobile patients.
C. Constipation: Constipation a common issue for patients on prolonged bedrest. The lack of movement reduces intestinal motility, leading to difficulty passing stools, which can become a serious concern if not managed properly.
D. Decreased cardiac workload: Immobility generally increases cardiac workload due to the body's need to compensate for the lack of activity. Prolonged bedrest leads to decreased circulation and muscle tone, placing additional strain on the heart.
E. Increased ventilation: Immobility leads to decreased ventilation, not increased. Prolonged bedrest can reduce lung expansion and the ability to clear secretions from the lungs, increasing the risk for respiratory complications such as atelectasis and pneumonia.
Correct Answer is A
Explanation
A. Measures to maximize independence: Health promotion involves enabling individuals to increase control over and improve their health. Teaching strategies that encourage self-care, mobility, nutrition, and personal responsibility support long-term wellness and independence.
B. Etiology and symptoms of an illness: This topic falls under illness prevention or disease education, focusing more on understanding and managing illness rather than promoting general health and wellness.
C. Hygiene and development issues: While important, this topic is more relevant to basic care or developmental guidance, and may align more with health maintenance or prevention depending on the context, rather than a primary focus on health promotion.
D. Introduction to parts of the healthcare team: This is oriented toward healthcare system navigation or orientation rather than actively promoting individual health behaviors and wellness practices.
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