An 85-year-old male who was hospitalized for a fractured hip ...

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An 85-year-old male who was hospitalized for a fractured hip develops difficulty breathing. The client has been receiving IV therapy for three days.
 
  When the nurse assesses the client, moist respirations are ausculated, a full bounding pulse and pedal edema are palpated and distended neck veins are noted. Based on the assessment, the nurse believes the most probable cause for the client's symptoms is:
  a. fluid overload. c. fat embolus.
  b. prolonged bed rest. d. inadequate diet.

Question 2

After the client begins taking the new medications, she develops periods of dizziness and confusion. The client's daughter calls to ask the nurse what she should do. The nurse's best response is:
 
  a. Don't worry. Confusion and dizziness are side effects of the new medications. Keep giving them. Your mother should get over the side effects soon.
  b. Keep your mother in bed for a while after giving the medications so she doesn't fall and hurt herself.
  c. Give the medications with food. The chance of side effects decreases when administered on a full stomach.
  d. Call the health care provider as soon as possible to report these symptoms.

[soda0602]

Answer to Question 1

ANS: A

Feedback
A Correct: This is a risk when administering IV fluids to the older adult.
B Incorrect: These are not the manifestations of prolonged bed rest.
C Incorrect: These are not manifestations of fat embolus.
D Incorrect: These are not manifestations of an inadequate diet.

Answer to Question 2

ANS: D

Feedback
A Incorrect: This is not a responsible nursing statement.
B Incorrect: This is not the best response, although it addresses a safety issue.
C Incorrect: This is not the best response; not all medications should be taken with food. In addition, the nurse is diagnosing the problem, which is not in her scope of practice.
D Correct: The health care provider should be notified of the client's symptoms, so possible adjustments to the medications or their dosages might be made.

[asan beg]

TYSM

[nanny]

Excellent