While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first?

Provide oxygen at 2 L per nasal cannula.

Provide a urinal and encourage the patient to void.

Place the patient in a high Fowler position.

Lay the patient flat in bed to listen to bowel sounds.

Answer and Explanation

The Correct Answer is C

A. Provide oxygen at 2 L per nasal cannula: Although oxygen might be helpful later, the patient currently has a good oxygen saturation (95%). The priority is to ease breathing and reduce fluid accumulation in the lungs.

B. Provide a urinal and encourage the patient to void: While voiding might help reduce fluid volume, repositioning the patient to improve breathing is more urgent.

C. Place the patient in a high Fowler position: This position maximizes lung expansion, improves oxygenation, and helps alleviate dyspnea caused by fluid overload.

D. Lay the patient flat in bed to listen to bowel sounds: Placing the patient flat can worsen pulmonary symptoms by allowing fluid to shift toward the lungs.

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Correct Answer is ["125"]

Explanation

To calculate the IV rate:

Rate(mL/hr) = Total volume /Time in hours

Rate(mL/hr) = 3000 ml /24 hrs

=125mL/hr

So, the IV pump should be set to 125 mL/hr.

A. Urine specific gravity 1.034 B. Distended neck veins C. BP 146/94 mm Hg D. Bounding pulse

Correct Answer is A

Explanation

A. Urine specific gravity 1.034: High urine specific gravity (greater than 1.030) indicates concentrated urine, which is a sign of dehydration. This suggests the kidneys are conserving water due to a lack of fluid.

B. Distended neck veins: Distended neck veins usually indicate fluid overload or hypervolemia, not dehydration.

C. BP 146/94 mm Hg: While elevated blood pressure could be a sign of various conditions, it is not a typical indicator of dehydration. Dehydration often leads to low blood pressure.

D. Bounding pulse: A bounding pulse is often associated with fluid overload or fever and does not indicate dehydration. In dehydration, the pulse may be weak or thready.

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While assessing an older adult patient with fluid excess, the nurse notes the following: T = 98.6°F, P = 92, R = 18, BP = 166/88 mm Hg, bilateral crackles, oxygen saturation = 95%. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with care of a client who has a prescription for 3,000 mL of intravenous fluids over the next 24 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round to the nearest whole number)

Correct Answer is ["125"]

Explanation

A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?

Correct Answer is A

Explanation

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