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 ["25"]

Explanation

Flowrate(gtt/min) = Volume /Time× Dropfactor(gtt/mL)

Rate= 100ml /60min×15 gtt/mL

= 25 gtt/min

A. The patient can experience speed shock B. A clot can be forced into the circulation causing serious complications. C. A painful arterial spasm can occur D. The catheter can become dislodged and fall out.

Correct Answer is B

Explanation

A. The patient can experience speed shock: Speed shock is a rapid infusion of a substance (like a medication or fluid) into the bloodstream, usually occurring when the infusion rate is too fast. This is not typically caused by flushing a clotted cannula.

B. A clot can be forced into the circulation causing serious complications: Flushing a clotted cannula too aggressively can dislodge a clot, causing it to travel into the bloodstream. This can lead to serious complications like embolism or stroke, especially if the clot is large or travels to a vital organ.

C. A painful arterial spasm can occur: While arterial spasms can occur, they are more often related to arterial catheterization or manipulation rather than flushing a venous cannula.

D. The catheter can become dislodged and fall out: While this could potentially happen, it is less of a concern compared to the risk of pushing a clot into circulation, which is a more immediate danger.

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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 preparing to administer dextrose 5% in water (DSW) 100 mL to infuse over 1 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number.)

Correct Answer is ["25"]

Explanation

Which of the following complications can occur if a clotted cannula is flushed too aggressively?

Correct Answer is B

Explanation

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