Author Question: The nurse is assessing a patient before hanging an IV solution of 0.9 NaCl with KCl in it. Which ... (Read 23 times)

LCritchfi · **on:** Jul 22, 2018

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

Question 2

The nurse is assisting an older adult patient, diagnosed with type 2 diabetes, with self-injection of insulin. What is the most appropriate intervention for this patient at discharge?

a. Arrange daily home visits for injections
b. Request an insulin pen prescription
c. Recommend upper arm injection sites
d. Supply patient with 100 unit insulin syringes

canderson530 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

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.

Answer to Question 2

ANS: B
An insulin pen will be the most effective method for injection for an older adult secondary to reduced eyesight and dexterity compared to using syringes. A 100 unit syringe has very small calibration marks and numbers, making it more difficult for older adults to see the appropriate doses. Daily home visits are not usually paid for by insurance. Most patients must learn to administer medications themselves. The upper arm subcutaneous site is too difficult for self-administration and may not be feasible for an older adult.