What nursing assessments/interventions should be completed prior to administering Isotonic IV solutions? (Select all that apply)

Elevate the head of the bed to 35-45 degrees unless contraindicated

Assess Vital Signs

Recheck MD orders post infusion

Assess lung and heart sounds

Obtain baseline weight

Review labs post infusion

Answer and Explanation

Correct Answer : A,B,D,E

Choice A rationale:
Elevate the head of the bed to 35-45 degrees unless contraindicated:
Promotes venous return: Elevating the head of the bed reduces venous pooling in the lower extremities and promotes venous return to the heart. This helps to improve cardiac output and reduce the risk of fluid overload.
Reduces aspiration risk: Elevating the head of the bed also helps to prevent aspiration, as it keeps the head and neck in a more upright position. This allows for better drainage of secretions and reduces the chance of them entering the lungs.
Contraindications: There are a few contraindications to elevating the head of the bed, such as severe hypotension, head injury, or spinal injury. In these cases, the potential benefits of elevation must be weighed against the risks.
Choice B rationale:
Assess Vital Signs:
Baseline assessment: It's crucial to obtain baseline vital signs before administering any IV fluid to have a reference point for comparison. This allows for early detection of any changes that may indicate fluid overload or other complications.
Monitoring fluid status: Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, provide important information about the patient's fluid status and hemodynamic stability. Changes in vital signs can signal fluid overload, dehydration, or other problems that may require intervention.
Detecting adverse reactions: Vital signs can also help to detect adverse reactions to the IV fluid, such as allergic reactions or anaphylaxis. Early identification of these reactions is essential for prompt treatment.
Choice D rationale:
Assess lung and heart sounds:
Baseline assessment: Assessing lung and heart sounds before IV fluid administration provides a baseline for comparison and helps to identify any preexisting conditions that may affect fluid tolerance.
Detecting fluid overload: Crackles in the lungs, increased heart rate, and extra heart sounds can indicate fluid overload, which can lead to pulmonary edema and heart failure.
Monitoring response to therapy: Lung and heart sounds can also be used to monitor the patient's response to IV fluid therapy. Improvement in lung sounds and heart rate can indicate a positive response to treatment.
Choice E rationale:
Obtain baseline weight:
Accurate fluid balance: Obtaining a baseline weight is essential for accurate assessment of fluid balance. It allows for tracking of fluid gains and losses and helps to prevent fluid overload or dehydration.
Monitoring fluid status: Changes in weight can reflect changes in fluid status. Weight gain can indicate fluid retention, while weight loss can suggest dehydration.

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Correct Answer is C

Explanation

Choice A rationale:
While providing information about post-operative care and pain management is important, it may not directly address the patient's underlying anxiety or encourage them to express their concerns.
It could be perceived as dismissive of their feelings or as an attempt to control the conversation. It focuses on the future rather than the patient's present experience.
Choice B rationale:
This response, while intended to be reassuring, may minimize the patient's individual experience and feelings. It could make the patient feel as though their concerns are not being taken seriously.
It implies that anxiety is a normal and expected reaction, which may discourage the patient from sharing their specific worries.
Choice C rationale:
This response is open-ended and invites the patient to share their thoughts and feelings.
It demonstrates active listening and encourages the patient to take an active role in the conversation.
It allows the nurse to assess the patient's understanding of the surgery and to address any misconceptions or concerns. It conveys a sense of empathy and understanding, which can help to build trust and rapport with the patient.
Choice D rationale:
While offering to explain the procedure may be helpful, it may not be what the patient needs at the moment. It could overwhelm the patient with information, particularly if they are already feeling anxious.
It could shift the focus away from the patient's emotional needs and onto the technical aspects of the surgery.

A. Advancing age B. Exposure to tobacco C. Exposure to occupational chemicals D. Infection with an oncovirus.

Correct Answer is B

Explanation

Choice A rationale:
While advancing age is a significant risk factor for cancer, it is not considered the single biggest risk factor. The risk of developing cancer does increase with age, primarily due to the accumulation of DNA damage over time. This damage can arise from various sources, including exposure to carcinogens, errors in DNA replication, and oxidative stress. With age, the body's ability to repair DNA damage also declines, making cells more susceptible to cancerous changes.
However, it's important to note that cancer can develop at any age, and even younger individuals can be affected if exposed to other significant risk factors.
Choice B rationale:
Exposure to tobacco is widely recognized as the single biggest risk factor for developing cancer. It is estimated to be responsible for about 25-30% of all cancer deaths worldwide.
Tobacco smoke contains over 70 known carcinogens, which are substances that can damage DNA and lead to cancer. These carcinogens can affect various organs in the body, including the lungs, mouth, throat, esophagus, stomach, pancreas, liver, bladder, kidney, cervix, and colon.
The risk of cancer increases with the amount and duration of tobacco use. Even exposure to secondhand smoke can increase the risk of cancer.
Quitting tobacco use is the most effective way to reduce the risk of cancer.
Choice C rationale:
Exposure to occupational chemicals is a known risk factor for certain types of cancer, such as lung cancer, bladder cancer, and leukemia. However, it is not considered the single biggest risk factor for developing cancer overall.
The risk of cancer from occupational chemicals depends on the specific chemical, the level of exposure, and the duration of exposure.
Workplace safety measures, such as using protective equipment and limiting exposure to hazardous chemicals, can help reduce the risk of cancer.
Choice D rationale:
Infection with certain viruses, known as oncoviruses, can increase the risk of developing certain types of cancer. For example, infection with human papillomavirus (HPV) can increase the risk of cervical cancer, and infection with hepatitis B virus (HBV) can increase the risk of liver cancer.
However, oncoviruses are not considered the single biggest risk factor for developing cancer overall. Vaccines are available to protect against some oncoviruses, such as HPV and HBV.

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What nursing assessments/interventions should be completed prior to administering Isotonic IV solutions? (Select all that apply)

Nursing Test Bank

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Correct Answer is C

Explanation

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Correct Answer is B

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