NLE Practice Test 3a - Pt. 3

1. When evaluating a client's response to fluid replacement therapy, the observation that indicates adequate tissue perfusion to vital organ is;

Urinary output of 30 ml in an hour

Central venous pressure reading of 2 cm H20

Pulse rates of 120 and 110 in a 15- minute period

Blood pressure readings of 50/30 and 70/40 mm Hg within 30 minutes

An adequate urinary output of 30 ml in an hour indicates that the client's kidneys are functioning properly and are able to filter and excrete waste products. This suggests that there is adequate blood flow to the kidneys, which is a sign of adequate tissue perfusion to vital organs.

Explanation

An adequate urinary output of 30 ml in an hour indicates that the client's kidneys are functioning properly and are able to filter and excrete waste products. This suggests that there is adequate blood flow to the kidneys, which is a sign of adequate tissue perfusion to vital organs.

2. After a Whippie procedure for cancer of the pancreas, a client is to receive the following intravenous (IV) fluids over 24 hours; 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. The nurse calculates that the clients IV fluid intake Tor 24 hours will be:

3150ml

3200 ml

3650 ml

3750ml

The client will receive 1000 ml D5W, 0.5 liter normal saline (which is equivalent to 500 ml), and 1500 ml D5NS over 24 hours. Additionally, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours, which means a total of 150 ml (50 ml x 3) will be administered. Adding up all these amounts, the client's IV fluid intake for 24 hours will be 3150 ml.

Explanation

The client will receive 1000 ml D5W, 0.5 liter normal saline (which is equivalent to 500 ml), and 1500 ml D5NS over 24 hours. Additionally, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours, which means a total of 150 ml (50 ml x 3) will be administered. Adding up all these amounts, the client's IV fluid intake for 24 hours will be 3150 ml.

3. The nurse, in assessing the adequacy of a client's fluid replacement during the first 2 to 3 days following full-thickness burns to the trunk and right thigh, would be aware that the most significant data would be obtained from recording

Weights every day .

Urinary output every hour

Blood pressure every 15 minutes

Extent of peripheral edema every 4 hours

The most significant data for assessing the adequacy of a client's fluid replacement following burns would be obtained from recording urinary output every hour. This is because monitoring urinary output provides valuable information about the client's fluid balance and kidney function. It helps determine if the client is adequately hydrated and if the fluid replacement therapy is effective in maintaining fluid balance. Monitoring urinary output every hour allows for early detection of any changes or abnormalities in urine output, which can indicate inadequate fluid replacement or potential complications such as renal dysfunction.

Explanation

The most significant data for assessing the adequacy of a client's fluid replacement following burns would be obtained from recording urinary output every hour. This is because monitoring urinary output provides valuable information about the client's fluid balance and kidney function. It helps determine if the client is adequately hydrated and if the fluid replacement therapy is effective in maintaining fluid balance. Monitoring urinary output every hour allows for early detection of any changes or abnormalities in urine output, which can indicate inadequate fluid replacement or potential complications such as renal dysfunction.

4. The dietary practice that will help a client reduce the dietary intake of sodium is

Increasing the use of dairy products

Using an artificial sweetener in coffee

Avoiding the use of carbonated beverages

Using catsup for cooking and flavoring foods

Carbonated beverages often contain high amounts of sodium, which can contribute to an increased dietary intake of sodium. By avoiding the use of carbonated beverages, the client can reduce their overall sodium intake.

Explanation

Carbonated beverages often contain high amounts of sodium, which can contribute to an increased dietary intake of sodium. By avoiding the use of carbonated beverages, the client can reduce their overall sodium intake.

5. Serum albumin Is to be administered intravenously to client with ascites, The expected outcome of this treatment will be a decrease in:

Urinary output

Abdominal girth

Serum ammonia level

Hepatic encephalopathy

Administering serum albumin intravenously to a client with ascites can help decrease abdominal girth. Ascites is the accumulation of fluid in the abdominal cavity, leading to abdominal distension. Serum albumin helps to increase the oncotic pressure in the blood vessels, which helps to draw fluid back into the blood vessels from the abdominal cavity, reducing abdominal girth. Therefore, the expected outcome of this treatment would be a decrease in abdominal girth.

Explanation

Administering serum albumin intravenously to a client with ascites can help decrease abdominal girth. Ascites is the accumulation of fluid in the abdominal cavity, leading to abdominal distension. Serum albumin helps to increase the oncotic pressure in the blood vessels, which helps to draw fluid back into the blood vessels from the abdominal cavity, reducing abdominal girth. Therefore, the expected outcome of this treatment would be a decrease in abdominal girth.

6. The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of:

Filtration

Diffusion

Osmosis

Active Transport

Osmosis is the process by which water molecules move from an area of lower solute concentration to an area of higher solute concentration through a semipermeable membrane. In the case of intravenous administration of albumin, albumin is a solute that creates a higher solute concentration in the bloodstream. As a result, water molecules move from the interstitial fluid into the bloodstream through osmosis to balance the solute concentration. Therefore, osmosis is the correct process associated with the shift of body fluids during the administration of albumin.

Explanation

Osmosis is the process by which water molecules move from an area of lower solute concentration to an area of higher solute concentration through a semipermeable membrane. In the case of intravenous administration of albumin, albumin is a solute that creates a higher solute concentration in the bloodstream. As a result, water molecules move from the interstitial fluid into the bloodstream through osmosis to balance the solute concentration. Therefore, osmosis is the correct process associated with the shift of body fluids during the administration of albumin.

7. When monitoring for hypernatremia, the nurse should assess the client for:

Dry skin

Confusion

Tachycardia

Pale coloring

Hypernatremia is a condition characterized by high levels of sodium in the blood. One of the common symptoms of hypernatremia is confusion. This occurs because high sodium levels can disrupt the normal functioning of the brain and nervous system. Confusion may manifest as disorientation, difficulty concentrating, or changes in behavior. Therefore, when monitoring for hypernatremia, the nurse should assess the client for confusion as it is a significant indicator of this condition.

Explanation

Hypernatremia is a condition characterized by high levels of sodium in the blood. One of the common symptoms of hypernatremia is confusion. This occurs because high sodium levels can disrupt the normal functioning of the brain and nervous system. Confusion may manifest as disorientation, difficulty concentrating, or changes in behavior. Therefore, when monitoring for hypernatremia, the nurse should assess the client for confusion as it is a significant indicator of this condition.

8. A client with ascites has a paracentesis, and 1500 ml of fluid is removed. Immediately following the procedure it is most important for the nurse to observe for:

A rapid, thready pulse

Decreased peristalsis .

Respiratory congestion

An increased in temperature

After a paracentesis, the nurse should observe for decreased peristalsis. Paracentesis involves the removal of fluid from the abdomen, which can lead to a decrease in bowel motility. This can result in decreased peristalsis, leading to symptoms such as abdominal distention, nausea, and vomiting. Therefore, it is important for the nurse to monitor for signs of decreased peristalsis to ensure the client's comfort and prevent complications.

Explanation

After a paracentesis, the nurse should observe for decreased peristalsis. Paracentesis involves the removal of fluid from the abdomen, which can lead to a decrease in bowel motility. This can result in decreased peristalsis, leading to symptoms such as abdominal distention, nausea, and vomiting. Therefore, it is important for the nurse to monitor for signs of decreased peristalsis to ensure the client's comfort and prevent complications.

9. A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;

13 gtt/min

16 gtt/min

29 gtt/min

32 gtt/min

The nurse should set the drip rate at 29 gtt/min because the total volume of fluids to be administered is 2750 ml (1500 ml D5W + 1250 ml NS). The nurse should divide the total volume by the time in minutes (24 hours = 1440 minutes) to determine the drip rate. Therefore, 2750 ml / 1440 min = 1.91 ml/min. Since the IV tubing has a drop factor of 15 gtt/ml, the nurse should multiply the drip rate in ml/min by the drop factor to get the drip rate in gtt/min. Therefore, 1.91 ml/min * 15 gtt/ml = 28.65 gtt/min, which should be rounded up to 29 gtt/min.

Explanation

The nurse should set the drip rate at 29 gtt/min because the total volume of fluids to be administered is 2750 ml (1500 ml D5W + 1250 ml NS). The nurse should divide the total volume by the time in minutes (24 hours = 1440 minutes) to determine the drip rate. Therefore, 2750 ml / 1440 min = 1.91 ml/min. Since the IV tubing has a drop factor of 15 gtt/ml, the nurse should multiply the drip rate in ml/min by the drop factor to get the drip rate in gtt/min. Therefore, 1.91 ml/min * 15 gtt/ml = 28.65 gtt/min, which should be rounded up to 29 gtt/min.

10. A client with a history of cardiac dysrhythmias is admitted to the hospital with the diagnosis of dehydration. The nurse should anticipate that the physician will order;

A glass of water every hour until hydrated

Small frequent intake of juices, broth, or milk

Short-term NG replacement of fluids and nutrients

A rapid IV infusion of an electrolyte and glucose solution

Given the client's history of cardiac dysrhythmias and the diagnosis of dehydration, the physician is likely to order small frequent intake of juices, broth, or milk. This is because these fluids are easier to tolerate and can help rehydrate the client gradually without putting too much strain on the heart. A glass of water every hour may be too much fluid intake at once and could potentially worsen the client's condition. Short-term NG replacement of fluids and nutrients may not be necessary if the client can tolerate oral intake. A rapid IV infusion of an electrolyte and glucose solution may be indicated in severe cases of dehydration, but it is not typically the first-line treatment.

Explanation

Given the client's history of cardiac dysrhythmias and the diagnosis of dehydration, the physician is likely to order small frequent intake of juices, broth, or milk. This is because these fluids are easier to tolerate and can help rehydrate the client gradually without putting too much strain on the heart. A glass of water every hour may be too much fluid intake at once and could potentially worsen the client's condition. Short-term NG replacement of fluids and nutrients may not be necessary if the client can tolerate oral intake. A rapid IV infusion of an electrolyte and glucose solution may be indicated in severe cases of dehydration, but it is not typically the first-line treatment.