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A patient is receiving a 3% saline continuous IV infusion for hyponatremia. Which assessment data will require the most rapid response by the nurse?
- A. The patient's radial pulse is 105 beats/minute.
- B. There is sediment and blood in the patient's urine.
- C. The blood pressure increases from 120/80 to 142/94.
- D. There are crackles audible throughout both lung fields.
Correct Answer: D
Rationale: Crackles throughout both lungs suggest that the patient may be experiencing pulmonary edema, a life-threatening adverse effect of hypertonic solutions. The increased pulse rate and blood pressure and the presence of sediment and blood in the urine should also be reported, but they are not as immediately dangerous as the presence of fluid in the alveoli, which compromises gas exchange and can lead to respiratory failure.
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A nurse is assessing a newly admitted patient with chronic heart failure who forgot to take prescribed medications and seems confused. The patient complains of "just blowing up" and has peripheral edema and shortness of breath. Which assessment should the nurse complete first?
- A. Skin turgor
- B. Heart sounds
- C. Mental status
- D. Capillary refill
Correct Answer: C
Rationale: Increases in extracellular fluid (ECF) can lead to swelling of cells in the central nervous system, initially causing confusion, which may progress to coma or seizures. Although skin turgor, capillary refill, and heart sounds also may be affected by increases in ECF, these are signs that do not have as immediate impact on patient outcomes as cerebral edema.
An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
- A. K+ 3.4 mEq/L (3.4 mmol/L)
- B. Ca+2 7.8 mg/dL (1.95 mmol/L)
- C. Na+ 154 mEq/L (154 mmol/L)
- D. PO4-3 4.8 mg/dL (1.55 mmol/L)
Correct Answer: C
Rationale: The correct answer is C. The elevated serum sodium level (154 mEq/L) is consistent with the patient's neurologic symptoms of restlessness, agitation, and weakness, indicating a need for immediate action to prevent complications like seizures. The potassium level (3.4 mEq/L) and calcium level (7.8 mg/dL) are slightly off from normal but do not require immediate action. The phosphate level (4.8 mg/dL) is normal and not related to the symptoms presented by the patient.
IV potassium chloride (KCl) 60 mEq is prescribed for the treatment of a patient with severe hypokalemia. Which action should the nurse take?
- A. Administer the KCl as a rapid IV bolus.
- B. Infuse the KCl at a rate of 10 mEq/hour.
- C. Only give the KCl through a central venous line.
- D. Discontinue cardiac monitoring during the infusion.
Correct Answer: B
Rationale: The correct action for the nurse to take is to infuse the KCl at a rate of 10 mEq/hour. Rapid IV infusion of KCl can lead to cardiac arrest due to its potential for causing hyperkalemia. While KCl can be administered through peripheral veins, central venous lines are not necessary unless specified. It is crucial to continue cardiac monitoring during potassium infusion to promptly identify and manage any potential dysrhythmias that may occur.
A client with bladder cancer had surgical placement of a ureteroileostomy (ileal conduit) yesterday. Which postoperative assessment finding should the nurse report to the healthcare provider immediately?
- A. red and edematous stoma appearance
- B. liquid brown drainage from stoma
- C. stoma output of 40ml in the last hour
- D. mucous strings floating in the drainage
Correct Answer: C
Rationale: Stoma output of only 40ml in the last hour may indicate a problem, such as dehydration or blockage, and should be reported immediately. A red and edematous stoma appearance could be due to inflammation, which is expected in the early postoperative period. Liquid brown drainage from the stoma is a normal finding. Mucous strings floating in the drainage are also a common occurrence postoperatively and do not typically require immediate reporting.
How should the nurse interpret the following arterial blood gas results for a patient who had a tracheostomy placed after a motor vehicle crash: pH 7.48, PaO2 85 mm Hg, PaCO2 32 mm Hg, and HCO3 25 mEq/L?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The patient's pH of 7.48 indicates alkalosis, and the low PaCO2 of 32 mm Hg suggests a respiratory cause. The HCO3 level is normal, ruling out metabolic causes. Therefore, the correct interpretation is respiratory alkalosis. Options A, B, and C are incorrect as they do not align with the pH and PaCO2 values provided.