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The patient weighs 75 kg and is receiving IV fluids at a rate of 50 mL/hour, having consumed 100 mL orally in the past 24 hours. What action will the nurse take?
- A. Contact the provider to ask about increasing the IV rate to 90 mL/hour.
- B. Discuss with the provider the need to increase the IV rate to 150 mL/hour.
- C. Encourage the patient to drink more water so the IV can be discontinued.
- D. Instruct the patient to drink 250 mL of water every 8 hours.
Correct Answer: A
Rationale: The recommended daily fluid intake for adults is 30 to 40 mL/kg/day. For a patient weighing 75 kg, the minimum intake should be 2250 mL/day. The patient is currently receiving 1200 mL IV and 100 mL orally, totaling 1300 mL. Increasing the IV rate to 90 mL/hour would provide a total of 2160 mL, which could meet the patient's needs if oral intake continues. Option B suggests increasing the IV rate to 150 mL/hour, resulting in an excessive fluid intake of 3600 mL/day, surpassing the recommended amount. Option C, encouraging increased fluid intake, is not recommended as the patient is already struggling with fluid intake. Option D, instructing the patient to drink 250 mL of water every 8 hours, would still fall short of the required fluid intake of 2250 mL/day.
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A client with polycystic kidney disease (PKD is being assessed by a nurse. Which assessment finding should prompt the nurse to immediately contact the healthcare provider?
- A. Flank pain
- B. Periorbital edema
- C. Bloody and cloudy urine
- D. Enlarged abdomen
Correct Answer: B
Rationale: Periorbital edema would not typically be associated with polycystic kidney disease (PKD) and could indicate other underlying issues that require immediate attention. Flank pain and an enlarged abdomen are common findings in PKD due to kidney enlargement and displacement of other organs. Bloody or cloudy urine can result from cyst rupture or infection, which are expected in PKD. Therefore, periorbital edema is the most alarming finding in this scenario and warrants prompt notification of the healthcare provider.
What is an ideal goal of treatment set by the nurse in the care plan for a client diagnosed with chronic kidney disease (CKD) to reduce the risk of pulmonary edema?
- A. Maintaining oxygen saturation above 92%
- B. Absence of crackles and wheezes in lung sounds
- C. Maintaining a balanced intake and output
- D. Absence of shortness of breath at rest
Correct Answer: C
Rationale: The ideal goal of treatment for a client with chronic kidney disease (CKD) to reduce the risk of pulmonary edema is to maintain a balanced intake and output. This helps in achieving optimal fluid balance, enabling the heart to eject blood effectively without increasing pressure in the left ventricle and pulmonary vessels. While maintaining oxygen saturation above 92% is important for adequate tissue oxygenation, the primary focus in this scenario is fluid balance. Absence of crackles and wheezes in lung sounds is important to assess for pulmonary status, but it is not the primary goal to prevent pulmonary edema specifically. Similarly, absence of shortness of breath at rest is a relevant goal, but the emphasis in CKD management is on fluid balance to prevent pulmonary complications.
The nurse is preparing to administer trimethoprim-sulfamethoxazole (TMP-SMX) to a patient who is being treated for a urinary tract infection. The nurse learns that the patient has type 2 diabetes mellitus and takes a sulfonylurea oral antidiabetic drug. The nurse will monitor this patient closely for which effect?
- A. Headaches
- B. Hypertension
- C. Hypoglycemia
- D. Superinfection
Correct Answer: C
Rationale: When a patient takes oral antidiabetic agents (sulfonylurea) along with sulfonamides like trimethoprim-sulfamethoxazole, it can lead to an increased hypoglycemic effect. Therefore, the nurse should monitor the patient closely for hypoglycemia. Headaches, hypertension, and superinfection are not typically associated with the interaction between sulfonamides and sulfonylureas. Examples of antidiabetic sulfonylurea medications include glipizide, glimepiride, glyburide, tolazamide, and tolbutamide.
After educating a client with stress incontinence, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
- A. I will limit my total intake of fluids.
- B. I must avoid drinking alcoholic beverages.
- C. I must avoid drinking caffeinated beverages.
- D. I shall try to lose about 10% of my body weight.
Correct Answer: A
Rationale: The correct answer is A. Limiting fluids can worsen stress incontinence by concentrating urine and irritating tissues, leading to increased incontinence. Adequate hydration is important to maintain bladder health and function. Choices B and C are correct as avoiding alcoholic and caffeinated beverages can help reduce bladder irritation. Choice D is also correct as losing about 10% of body weight can help reduce intra-abdominal pressure, which is beneficial in managing stress incontinence.
A client with elevated levels of antidiuretic hormone (ADH) triggers the release of this hormone due to which disorder?
- A. Pneumonia
- B. Dehydration
- C. Renal failure
- D. Edema
Correct Answer: B
Rationale: Antidiuretic hormone (ADH) increases tubular permeability to water, causing more water absorption into the capillaries. ADH is released in response to a rising extracellular fluid osmolarity, such as in dehydration. Pneumonia, renal failure, and edema do not typically lead to the release of ADH. Pneumonia is an inflammatory lung condition, renal failure affects kidney function, and edema is the accumulation of excess fluid in the tissues, none of which directly stimulate the release of ADH.