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 B

Explanation

A. Hypotension: Hypercalcemia (high calcium levels) typically causes increased blood pressure, not hypotension.

B. Decreased deep tendon reflexes: High calcium levels can depress neuromuscular function, leading to diminished or absent deep tendon reflexes. This is a common finding in hypercalcemia.

C. Diarrhea: Hypercalcemia is more commonly associated with constipation, not diarrhea.

D. Increased appetite: Hypercalcemia does not cause increased appetite. It often leads to symptoms such as nausea, vomiting, or a reduced appetite.

A. Hematoma B. Phlebitis C. Speed Shock D. Thrombosis

Correct Answer is B

Explanation

A. Hematoma: A hematoma typically results from bleeding into the tissue, causing swelling and bruising at the infusion site, but it doesn't usually cause warmth or pain in the same way as phlebitis.

B. Phlebitis: Phlebitis is inflammation of the vein, commonly caused by an IV catheter or medication, and it often presents with redness, warmth, pain, and swelling at the infusion site. It is the most likely complication here.

C. Speed Shock: Speed shock occurs when a medication or fluid is administered too rapidly, causing symptoms such as dizziness, chest tightness, and hypotension, not localized symptoms like redness and pain at the infusion site.

D. Thrombosis: Thrombosis refers to the formation of a blood clot within a vein, which can cause swelling, warmth, and discomfort but would also likely involve more significant blockage and would be associated with reduced blood flow, not just localized redness and pain.

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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 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?

Correct Answer is B

Explanation

An 87-year-old patient recovering from abdominal surgery has a continuous intravenous infusion to supply nutrients and antibiotics. What complication should you suspect when signs and symptoms of redness, warmth, and pain at the infusion site are reported?

Correct Answer is B

Explanation

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

A nurse is collecting data from a client who has hypocalcemia. Which of the following findings should the nurse expect?

The IV infusion pump for a patient receiving an IV therapy begins to alarm and displays occlusion. When the silence button is pushed, the alarm quickly resumes. Which action should the nurse take first?

A nurse is collecting data from a client who has a sodium level of 155 mEq/L (136-145 mEq/L). Which of the following manifestations should the nurse expect?

A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?

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?

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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)