Author Question: The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving ... (Read 111 times)

K@

  • Hero Member
  • *****
  • Posts: 608
The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO.
 
  Which assessment finding would be a priority for the nurse to report to the health care provider?
  a. Oral temperature of 100.1 F
  b. Serum sodium level of 138 mEq/L (138 mmol/L)
  c. Gradually decreasing level of consciousness (LOC)
  d. Weight gain of 2 pounds (1 kg) above the admission weight

Question 2

An older patient receiving iso-osmolar continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately?
 
  a. K+ 3.4 mEq/L (3.4 mmol/L)
  b. Ca+2 7.8 mg/dL (1.95 mmol/L)
  c. Na+ 154 mEq/L (154 mmol/L)
  d. PO4-3 4.8 mg/dL (1.55 mmol/L)



zogaridan

  • Sr. Member
  • ****
  • Posts: 328
Answer to Question 1

ANS: C
The patient's history and change in LOC could be indicative of fluid and electrolyte disturbances: extracellular fluid (ECF) excess, ECF deficit, hyponatremia, hypernatremia, hypokalemia, or metabolic alkalosis. Further diagnostic information is needed to determine the cause of the change in LOC and the appropriate interventions. The weight gain, elevated temperature, crackles, and serum sodium level also will be reported, but do not indicate a need for rapid action to avoid complications.

Answer to Question 2

ANS: C
The elevated serum sodium level is consistent with the patient's neurologic symptoms and indicates a need for immediate action to prevent further serious complications such as seizures. The potassium and calcium levels vary slightly from normal but do not require immediate action by the nurse. The phosphate level is normal.



Related Topics

Need homework help now?

Ask unlimited questions for free

Ask a Question


 

Did you know?

The liver is the only organ that has the ability to regenerate itself after certain types of damage. As much as 25% of the liver can be removed, and it will still regenerate back to its original shape and size. However, the liver cannot regenerate after severe damage caused by alcohol.

Did you know?

Complications of influenza include: bacterial pneumonia, ear and sinus infections, dehydration, and worsening of chronic conditions such as asthma, congestive heart failure, or diabetes.

Did you know?

Since 1988, the CDC has reported a 99% reduction in bacterial meningitis caused by Haemophilus influenzae, due to the introduction of the vaccine against it.

Did you know?

When blood is deoxygenated and flowing back to the heart through the veins, it is dark reddish-blue in color. Blood in the arteries that is oxygenated and flowing out to the body is bright red. Whereas arterial blood comes out in spurts, venous blood flows.

Did you know?

During the twentieth century, a variant of the metric system was used in Russia and France in which the base unit of mass was the tonne. Instead of kilograms, this system used millitonnes (mt).

For a complete list of videos, visit our video library