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 A

Explanation

A. Upright: Sitting upright promotes optimal lung expansion by reducing pressure on the diaphragm and improving ventilation.

B. Side-lying: This may be used for comfort but does not maximize lung expansion.

C. Supine: Lying flat can compromise lung expansion, particularly in respiratory distress.

D. Prone: While prone positioning is used in specific cases of severe respiratory failure (e.g., ARDS), it is not standard for general pneumonia in children.

A. Weak pulse B. Distended neck veins C. Bradycardia D. Pitting Edema

Correct Answer is A

Explanation

A. Weak pulse: Isotonic fluid-volume deficit results in decreased blood volume, leading to reduced cardiac output and a weak, thready pulse.

B. Distended neck veins: This is associated with fluid volume excess, not deficit.

C. Bradycardia: Fluid deficit typically leads to tachycardia as the body compensates for decreased circulating volume.

D. Pitting edema: This is a sign of fluid overload rather than deficit.

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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 the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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