The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician?
a. Weight gain of 2 pounds since last week
b. Dry mucous membranes and skin tenting
c. Urine output 8 mL/hr
d. Blood pressure 98/58
ANS: C
Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. An overnight weight gain indicates a fluid gain.
You might also like to view...
A two-month-old infant is a direct admission to the pediatric unit with a diagnosis of ALTE (apparent life-threatening event). The physician is to see the infant to write medical orders
The nurse completes the nursing history and performs an assessment and finds no abnormal findings. While waiting on the physician, which activity can the nurse perform independently? 1. Place the child on an apnea monitor. 2. Place the child on nasal cannula oxygen. 3. Draw blood for arterial blood gases. 4. Place the child on contact isolation.
Teaching of a patient with peripheral vascular disease (PVD) should include
a. Uncrossing legs, avoiding temperature ex-tremes, using cotton socks b. Keeping legs dependent, avoiding temperature extremes, and avoiding constricting clothing c. Avoiding constricting clothing, avoiding infection, having one glass of red wine per day d. Applying salve with gauze and tape to open areas, having one glass of red wine per day, avoiding temperature extremes
A mother brings her 7-year-old daughter to the mental health clinic. She tells the pediatric nurse that lately her daughter has been expressing worry about everything including her school and home life
The nurse suspects that the patient may be experiencing: A) panic disorder. B) separation anxiety disorder. C) generalized anxiety disorder. D) posttraumatic stress disorder.
Common causes of sensorineural hearing loss include:
a. Streptomycin, neomycin, or other ototoxic drugs b. Otitis media c. Injury d. Foreign bodies