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 C

Explanation

A. Potassium chloride: Potassium chloride is used to treat hypokalemia, not hyperkalemia.

B. Acetylcysteine: This medication is not used to treat potassium imbalances. It is primarily used to treat acetaminophen overdose or to thin mucus in respiratory conditions.

C. Sodium polystyrene: Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, helping to lower serum potassium levels.

D. Potassium iodide: Potassium iodide is used in thyroid conditions (such as thyroid storm) or radiation exposure and is not used to manage potassium levels.

A. Dextrose 10% in water B. Lactated Ringer's C. 0.33% sodium chloride D. 0.45% sodium chloride

Correct Answer is B

Explanation

A. Dextrose 10% in water: Dextrose solutions provide calories but do not restore volume or replace electrolytes. They are not typically used in hypovolemic shock.

B. Lactated Ringer's: Lactated Ringer’s solution is an isotonic solution containing sodium, potassium, calcium, and lactate, which helps restore both fluid volume and electrolytes in the case of hypovolemic shock. It is commonly used while awaiting blood transfusions.

C. 0.33% sodium chloride: This is a hypotonic solution that can cause fluid to shift into cells and is not appropriate for fluid resuscitation in hypovolemia, which requires an isotonic solution.

D. 0.45% sodium chloride: This is a hypotonic solution as well, and it could worsen hypotension by causing fluid shifts into the cells, which is not ideal for treating hypovolemic shock.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client whose serum potassium level is 5.3 mEq/L (3.5-5 mEq/L). The nurse should anticipate a prescription for which of the following medications?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who is hypovolemic due to blood loss following a motor-vehicle crash and needs a blood transfusion immediately. The nurse should anticipate a prescription for which of the following IV solutions while awaiting blood from a type and cross-match?

Correct Answer is B

Explanation

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)

The nurse is using Chvostek sign to assess for hypocalcemia. Which statement correctly describes this test?

The nurse is caring for a group of patients. Which patient is at highest risk for hypovolemia?

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?

Which of the following solutions can be administered with a blood component?

A nurse is collecting data from a client who has a calcium level of 12 mg/dL (9-10.5 mg/dL). Which of the following manifestations should the nurse expect?

A nurse is reviewing the laboratory values for a client who takes spironolactone and notes that the client's serum potassium level is 6.8 mEq/L (3.5 -5 mEq/L). The nurse notifies the provider and anticipates that the provider will provide which of the following instructions?

A nurse in a provider's office is collecting data from a client who takes furosemide daily for heart failure. Which of the following findings is a manifestation of hypokalemia?