Which IV solution would the nurse anticipate administering to a patient with fluid deficit who requires isotonic fluid replacement?

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.

Choice A: Properly cleaning all reusable equipment once each day

While cleaning reusable equipment is important, it should be done after each use, not just once a day. This ensures that any potential pathogens are removed before the equipment is used on another patient, thereby preventing cross-contamination.

Choice B: Appropriately using PPE

This is a correct answer. Personal Protective Equipment (PPE) such as gloves, masks, gowns, and eye protection are essential in preventing the spread of infection. Proper use of PPE helps protect both healthcare workers and patients from exposure to infectious agents.

Choice C: Ensuring all environmental surfaces are properly cleaned, disinfected, and maintained

This is another correct answer. Regular cleaning and disinfection of environmental surfaces, such as bed rails, doorknobs, and medical equipment, are crucial in preventing the spread of infections. Maintaining a clean environment reduces the risk of healthcare-associated infections.

Choice D: Avoiding all invasive interventions

Avoiding invasive interventions is not a practical or realistic approach to preventing infections. While minimizing unnecessary invasive procedures can reduce infection risk, many invasive interventions are necessary for patient care. Instead, proper aseptic techniques should be used during these procedures to prevent infections.

Choice E: Performing hand washing or using an alcohol-based hand sanitizer before and after patient contact or procedures

This is also a correct answer. Hand hygiene is one of the most effective measures to prevent the spread of infections. Washing hands with soap and water or using an alcohol-based hand sanitizer before and after patient contact or procedures significantly reduces the transmission of pathogens.