Author Question: The nurse is to administer an intravenous solution to a patient with diffuse edema. This will pull ... (Read 70 times)

joesmith1212 · **on:** Jul 23, 2018

The nurse is to administer an intravenous solution to a patient with diffuse edema. This will pull fluid from the interstitial space to the intravascular space. Which prescription would the nurse question for this patient? A prescription for:

a. 5 Dextrose in water (D5W)
b. 10 Dextrose in water (D10W)
c. 5 Dextrose in normal saline (D5 0.9 NaCl)
d. 5 Dextrose lactated Ringer's (D5LR)

Question 2

A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100 eschar.

What would the nurse identify this as?
a. Stage II pressure ulcer
b. Stage III pressure ulcer
c. Stage IV pressure ulcer
d. Unstageable pressure ulcer

Sierray · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

A
Edema is the presence of excess fluid within the interstitial spaces. Hypertonic fluids, when administered, pull fluids and electrolytes from the intracellular and interstitial compartments into the intravascular compartment. Hypertonic fluids can help stabilize blood pressure, increase urine output, and reduce edema. D10W, D5 0.9 NaCl, and D5 LR are all hypertonic fluids, so the nurse would likely not question a prescription for one of those. D5W, however, is hypotonic in the body, with a tendency to pull fluids out of the intravascular compartment into the interstitial compartment, and thus increase the patient's edema.

Answer to Question 2

D
An eschar is a black, leathery covering made up of necrotic tissue. An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth.