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Published by cruzjuan58

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Published by: cruzjuan58 on Jun 22, 2009
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Results ReporterSummary: 60% correct6 correct out of 104 incorrect answers0 unanswered questions1) Wrong Which of the following clients is at highest risk for developingfluid volume deficit?The correct answer: A 76-year-old client who has an NG tube to low suctionfollowing colon cancer surgeryYour answer: A 30-year-old client jogging in 50-degree weatherRationale: Infants and the elderly can't compensate as well for fluid losses.Clients with NG suction (loss of fluid and electrolytes in fairly proportionalamounts) are at greater risk for fluid volume deficit. The elderly client with NGsuction has both risk factors, while the child's age is the only risk factor. Theclient taking glucocorticoids is predisposed to sodium and fluid retention ratherthan fluid loss. The 30-year-old jogger is a young adult in a moderate climate,which lowers the risk from exertion alone.Cognitive Level: AnalysisNursing Process: Analysis; Test Plan: PHYS2) Correct Which of the following statements should not be included in aneducation program for the elderly about prevention of dehydration during hotweather?Your answer: "Use your thirst as a guide to the amount of fluid you should bedrinking."Rationale: With aging, the thirst mechanism becomes less effective. Significantfluid can be lost before thirst is triggered, so the elderly should not relysolely on thirst to indicate when they need to drink fluids. All of the otherchoices should be included in this type of education program.Cognitive Level: ApplicationNursing Process: Implementation; Test Plan: HPM3) Correct An adult client in the clinic complains of a cough, fever,nausea, and vomiting for three days. Examination reveals dry tongue and oralmucosa, and concentrated urine. The client also reports feeling weak and dizzy.Which vital sign measurement would provide the best indicator of current fluidstatus?Your answer: BP and pulse in lying and standing positionsRationale: The client has symptoms of fluid volume deficit and hypovolemia. Thepresence of postural hypotension when rising from a lying position indicates thepresence of significant hypovolemia. The other vital signs are important but donot directly reflect circulating fluid volume.Cognitive Level: AnalysisNursing Process: Assessment; Test Plan: PHYS4) Correct An intravenous (IV) infusion of normal saline is being initiatedfor a 10-month-old infant diagnosed with fluid volume deficit. The order states todeliver a 200 mL bolus, then reduce the fluid rate to 30 mL/hour. How should thenurse implement this therapy?Your answer: Control the fluid infusion rate using an infusion pump, checking itoften.
Rationale: An infusion pump should be used to control IV fluid rates on infantsreceiving IV fluids to avoid accidental fluid overload. Infusing by gravity andmonitoring only every hour does not protect from this risk, since the bolus may becompleted in less than half an hour. Placing responsibility for monitoring IVinfusions on the mother is not ethical, safe, or legally advisable.Cognitive Level: AnalysisNursing Process: Implementation; Test Plan: SECE5) Correct A 40-year-old client is hospitalized for gastrointestinal (GI)bleeding. Orders include nasogastric tube (NGT) placement with irrigations untilthe returns are clear. Which fluid should be used for the NG irrigations?Your answer: Normal salineRationale: Normal saline is an isotonic fluid that prevents fluid shifts into orout of the GI tract. Option 1 (3% saline) is hypertonic and could pull water fromthe GI tract, resulting in water loss. D5W and plain water are hypotonic and couldbe pulled into GI tissue as well as wash electrolytes out of the GI tract,resulting in water intoxication.Cognitive Level: ApplicationNursing Process: Implementation; Test Plan: SECE6) Wrong A 70-year-old client with a past medical history of hypertensionand myocardial infarction is in the hospital following stomach surgery. Vitalsigns have been stable and an IV of D51/2NS is infusing at 100 mL/hour. The clientnow complains of trouble breathing, has a moist cough, and pulse oximetry readinghas fallen to 92%. What action should the nurse take first?The correct answer: Slow the intravenous rate to 10 to 20 mL/hour.Your answer: Assess legs and arms for pitting edema.Rationale: A moist cough, dyspnea, and falling pulse oximetry reading in a clientwith a history of heart disease are signs of developing pulmonary edema secondaryto fluid volume overload. The first action should be to reduce IV fluid intake toprevent more fluid from accumulating in the lungs, then further assessment can bedone, emergency actions taken, and the physician contacted.Cognitive Level: AnalysisNursing Process: Implementation; Test Plan: SECE7) Correct A 45-year-old client diagnosed with fluid volume overload due toacute kidney dysfunction is placed on a 1,000 mL fluid restriction per 24-hourperiod. The client asks the nurse, "Why there is such a severe fluid restrictionwhen I already have dry lips and mouth?" Which response by the nurse is best?Your answer: "Your kidneys are not able to eliminate extra fluid right now, sofluid intake has to be limited to protect your heart and lungs from beingoverloaded with fluid."Rationale: Option 2 provides accurate information in simple terms without undulyalarming client. Option 4 is technically correct but is stated in an abrupt andalarming manner. Option 1 offers no explanation to facilitate understanding.Option 3 assigns the client blame for the current condition without providing aclear explanation for the fluid restriction.Cognitive Level: ApplicationNursing Process: Implementation; Test Plan: PSYC8) Wrong Which of the following is the best indicator of an excessiveresponse to diuretic therapy?The correct answer: Elevated blood urea nitrogen (BUN) and hematocrit (HCT) and an8-pound weight loss in 24 hours.Your answer: Decreased BUN and HCT and an 8- pound weight loss in 24 hours

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