HESI ONL: HU NSG527 Med Surg Nursing II Exam 2 Summer C
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Free HESI ONL: HU NSG527 Med Surg Nursing II Exam 2 Summer C Questions
A client is being treated for syndrome of inappropriate antidiuretic hormone (SIADH). Upon examination, the client has a weight gain of 4.4 lbs (2 kg) in 24 hours and an elevated pulse rate. Which intervention should the nurse implement first?
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Review arterial blood gas results.
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Ensure client takes a diuretic every morning.
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Measure ankle circumference.
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Record usual eating patterns.
Explanation
Correct Answer: (C) Measure ankle circumference. Following the nursing process, assessment should precede intervention. The client's rapid weight gain and elevated pulse rate suggest worsening fluid volume excess associated with SIADH. The nurse's first action should be to further assess the extent of fluid retention by measuring ankle circumference to check for peripheral edema before proceeding with treatment interventions.
Why Other Options are Incorrect:
A. Review arterial blood gas results. ABG results are not directly relevant to assessing fluid volume status in SIADH and would not be the priority assessment.
B. Ensure client takes a diuretic every morning. Administering a diuretic is an intervention, not an assessment, and should follow further evaluation of the client's current fluid status.
D. Record usual eating patterns. This does not address the client's acute weight gain and elevated pulse rate, which are more urgently related to fluid overload than dietary intake.
A 36-year-old male client is brought to the emergency department (ED) following a fall from a ladder approximately 12 ft (3.6 m) high. Reports falling onto his right side and is experiencing pain in his right arm, hip, and leg. Bruising is evident in the client's right thigh. Client denies losing consciousness or hitting his head. He is obese and is a current smoker, smoking one pack per day. Reports an intermittent productive cough for the past five years. Has an incomplete fracture to the right femur. Surgical consultation has been completed, and the client is being admitted to the orthopedic floor for surgery the following morning.
Nurses' Notes:
1400 — The client is admitted to the orthopedic unit. Initial prescriptions are placed by the healthcare provider (HCP) and an initial assessment and vital signs completed.
Assessment:
- Neurological: Alert and oriented to person, place, time, and situation. Full sensation bilateral lower extremities. Denies numbness and tingling.
- Cardiovascular: Heart sounds normal. Regular rhythm. Left leg 2+ dorsalis pedal pulses and 2+ posterior tibial pulses. Right leg 1+ dorsalis pedal pulses and 1+ posterior tibial pulses. Capillary refill 3 seconds bilateral lower extremities.
- Respiratory: Lung sounds are clear in all fields. No signs of respiratory distress, productive cough.
- Gastrointestinal: Denies nausea, vomiting, and diarrhea. Reported last bowel movement this morning.
- Genitourinary: Indwelling urinary catheter in place. Clear straw colored urine is visible in the catheter bag.
- Musculoskeletal: Full range of motion (ROM) in bilateral ankles. Throbbing pain 6 on a 0 to 10 scale reported in right upper leg. 3+ edema in right lower extremity.
20 gauge peripheral IV (PIV) catheter placed in the client's right forearm basilic vein. Secured and maintained per unit protocol. Client tolerated procedure well.
1430 — Tramadol 50 mg PO is given for throbbing pain reported 6 on a 0 to 10 scale in right hip.
1800 Assessment:
- Neurological: Lethargic and mildly confused. Full sensation bilateral lower extremities. Denies numbness and tingling.
- Cardiovascular: Heart sounds normal. Regular rhythm. Left leg 2+ dorsalis pedal pulses and 2+ posterior tibial pulses. Right leg 1+ dorsalis pedal pulses and 1+ posterior tibial pulses. Capillary refill 3 seconds bilateral lower extremities.
- Respiratory: Lung sounds are clear in all fields. No signs of respiratory distress, productive cough.
- Gastrointestinal: Denies nausea, vomiting, and diarrhea. Reported last bowel movement this morning.
- Genitourinary: Indwelling urinary catheter in place. Clear straw colored urine 160 mL output in 4 hours.
2030 — The client reports throbbing pain 8 on a 0 to 10 scale. Administered hydromorphone 0.5 mg IV push (IVP).
2200 — Acetaminophen 650 mg PO is given for throbbing pain reported 3 on a 0 to 10 scale.
2230 — The client reports throbbing pain 8 on a 0 to 10 scale. Administered hydromorphone 0.5 mg IVP.
Assessment:
- Neurological: Anxious. Full sensation bilateral lower extremities. Denies numbness and tingling.
- Cardiovascular: Heart rhythm normal though tachycardic. Diaphoretic. Left leg 3+ dorsalis pedal pulses and 3+ posterior tibial pulses. Right leg 1+ dorsalis pedal pulses and 1+ posterior tibial pulses. Capillary refill 3 seconds bilateral lower extremities. Petechiae on neck and upper chest.
- Respiratory: Fine crackles left lower lobe. Right lung sounds clear. Tachypneic. Dyspnea with use of accessory muscles.
- Gastrointestinal: Active bowel sounds.
- Genitourinary: Indwelling urinary catheter draining straw colored urine 130 mL output in 4 hours.
- Musculoskeletal: Full range of motion in left ankle, limited range of motion in right ankle. Reported pain 5 on a 0 to 10 scale in right hip and upper leg described as throbbing. 1+ edema in right lower extremity.
2330 — An emergent computed tomography (CT) scan is completed.
Later in the evening, the client called the nurse into the room reporting increased anxiety and reporting that something did not feel right. On quick assessment, the nurse noted that the client was diaphoretic and dyspneic. A full assessment and vital signs were completed. Oxygen was immediately applied, and the healthcare provider (HCP) was contacted. The HCP prescribed a STAT computed tomography (CT) scan for suspicion of a pulmonary embolism.
Flow Sheet:
- Body mass index (BMI): 32.1 kg/m² (normal 18 to 24.9 kg/m²)
1400: Temperature 98.1° F (36.7° C); Heart rate 85 beats/minute; Respirations 14 breaths/minute; Blood pressure 119/62 mm Hg; Oxygen saturation 98% on room air; Pain rating of 6 on a 0 to 10 scale, right leg
1800: Temperature 99° F (37.2° C) orally; Heart rate 81 beats/minute; Respirations 13 breaths/minute; Blood pressure 118/64 mm Hg; Oxygen saturation 99% on room air; Pain 4 on a 0 to 10 scale, right leg
2200: Temperature 98.7° F (37.1° C) orally; Heart rate 86 beats/minute; Respirations 15 breaths/minute; Blood pressure 126/72 mm Hg; Oxygen saturation 97% on room air; Pain 3 on a 0 to 10 scale, right leg
2300: Temperature 99.0° F (37.2° C); Heart rate 111 beats/minute; Respirations 22 breaths/minute; Blood pressure 137/84 mm Hg; Oxygen saturation 89% on room air; Pain rating of 5 on a 0 to 10 scale, right leg
Orders (1400):
- Bedrest
- Regular diet
- NPO at midnight
- Insert peripheral IV (PIV) catheter and maintain per unit protocol
- Acetaminophen 650 mg PO every 6 hours PRN for mild pain
- Tramadol 50 mg PO every 6 hours PRN for intermediate pain
- Hydromorphone 0.5 mg IV push (IVP) every 2 hours PRN for severe pain
- Place indwelling urinary catheter for immobility
- Report urinary output less than 30 mL/hour
- Titrate oxygen via nasal cannula 1 to 5 L/minute to keep oxygen saturation greater than 92%
2330 — Computed tomography (CT) chest ordered.
Imaging Studies (2330): Computed tomography (CT) chest: Pulmonary edema in right lung and patch distribution of opacities consistent with embolism.
Laboratory Studies — Day 2, 0230:
Arterial Blood Gas:
- pH: 7.30 — Reference range: 7.35 to 7.45
- PaCO2: 36 mm Hg — Reference range: 35 to 45 mm Hg
- HCO3-: 18 mEq/L (18 mmol/L) — Reference range: 22 to 26 mEq/L (22 to 26 mmol/L)
- PaO2: 59 mm Hg — Reference range: 80 to 100 mm Hg
Additional Labs:
- Erythrocyte sedimentation rate: 31 mm/hr — Reference range: Less than 15 mm/hr
- Serum calcium: 8.2 mg/dL (2.05 mmol/L) — Reference range: 9.5 to 10.5 mg/dL (2.25 to 2.62 mmol/L)
- Red blood cell count: 3.5 x 10⁶/μL (3.5 x 10¹²/L) — Reference range: 4.0 to 5.9 x 10⁶/μL (4.0 to 5.9 x 10¹²/L)
- Hemoglobin: 12 g/dL (120 g/L) — Reference range: 14 to 18 g/dL (140 to 180 g/L)
- Hematocrit: 40% (0.40 volume fraction) — Reference range: 42 to 52% (0.42 to 0.52 volume fraction)
- Platelet count: 100,000/mm³ (100 x 10⁹/L) — Reference range: 150,000 to 400,000/mm³ (150 to 400 x 10⁹/L)
- Triglycerides: 210 mg/dL (2.37 mmol/L) — Reference range: 40 to 160 mg/dL (0.45 to 1.81 mmol/L)
The client was treated for a pulmonary fat embolism with bedrest, fluid hydration, steroid therapy, and oxygenation.
Select 5 findings that indicate that the client is responding to treatments and may be ready for femur repair surgery.
I. Numbness in right lower extremity
-
Use of accessory muscles
-
Left leg 2+ dorsalis pedal pulses and right leg +1 dorsalis pedal pulses
-
Skin warm to touch
-
Normal pigmentation
-
Tachypneic
-
Full range of motion in right ankle
-
Pain localized to right hip and upper leg
-
Capillary refill 2 seconds bilateral lower extremities
-
I. Numbness in right lower extremity
Explanation
Correct Answer: (C, D, F, G, H) Skin warm to touch; Normal pigmentation; Full range of motion in right ankle; Pain localized to right hip and upper leg; Capillary refill 2 seconds bilateral lower extremities. These findings reflect resolution of the client's respiratory and neurovascular compromise. Skin that is warm to touch and shows normal pigmentation indicates adequate peripheral perfusion. Full range of motion in the right ankle demonstrates improved neuromuscular function in the affected limb. Pain that is now localized to the right hip and upper leg, rather than diffuse or worsening, suggests the absence of an evolving complication such as compartment syndrome. Capillary refill of 2 seconds bilaterally, improved from the earlier 3-second finding, indicates restored peripheral circulation. Together, these findings suggest the client's respiratory and vascular status has stabilized enough to proceed with femur repair surgery.
Why the other options are incorrect:
A. Use of accessory muscles. This indicates ongoing respiratory distress and would suggest the client is not ready for surgery.
B. Left leg 2+ dorsalis pedal pulses and right leg +1 dorsalis pedal pulses. This reflects a persistent discrepancy between the affected and unaffected limb, suggesting continued vascular compromise rather than improvement.
E. Tachypneic. This indicates ongoing respiratory distress, which is inconsistent with readiness for surgery.
I. Numbness in right lower extremity. New numbness is a concerning neurovascular finding and would indicate a complication rather than improvement.
74-year-old male client with ESRD, admitted for hyperkalemia and metabolic acidosis, now receiving hemodialysis via tunneled subclavian catheter.
Day 2, 0700:
Click to highlight the concerns the nurse would need to address in their assessment of the client.
I. Lung sounds have crackles in all lung fields
J. Client reports being very tired
K. Describes feeling short of breath when walking
L. Mucous membranes moist
M. Capillary refill less than 4 seconds
N. 2+ edema lower extremities
O. Weight 194 pounds (88 kg)
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Client has new placement of AV graft in right forearm
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Bruit and thrill present
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Area is tender but has minimal pain
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Subclavian dialysis catheter remains in place
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Dressing is dry and intact
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Weight gain of 2 pounds (0.9 kg) in 24 hours
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Blood pressure is 154/94 mm Hg
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Intake for past 12 hours 600 mL
-
I. Lung sounds have crackles in all lung fields
-
J. Client reports being very tired
-
K. Describes feeling short of breath when walking
-
L. Mucous membranes moist
-
M. Capillary refill less than 4 seconds
-
N. 2+ edema lower extremities
-
O. Weight 194 pounds (88 kg)
Explanation
Correct Answer: (F, G, I, K, N) Weight gain of 2 pounds (0.9 kg) in 24 hours; Blood pressure is 154/94 mm Hg; Lung sounds have crackles in all lung fields; Describes feeling short of breath when walking; 2+ edema lower extremities. These findings together indicate fluid volume overload, a common complication in clients with ESRD, particularly between dialysis sessions. A weight gain of 2 pounds in 24 hours reflects fluid retention. Elevated blood pressure of 154/94 mm Hg is consistent with excess intravascular volume. Crackles in all lung fields suggest fluid accumulation in the lungs, indicating pulmonary edema. Shortness of breath with exertion further supports impaired gas exchange from fluid overload. 2+ edema in the lower extremities is a classic sign of excess extracellular fluid. Together, these findings warrant prompt nursing attention and likely earlier dialysis or fluid management intervention.
Why Other Options are Not Priority Concerns:
A. Client has new placement of AV graft in right forearm. This is an expected finding, as the AV graft is being established as a long-term dialysis access site.
B. Bruit and thrill present. This is a normal, expected finding for a functioning AV graft, indicating adequate blood flow.
C. Area is tender but has minimal pain. Mild tenderness is expected after a new graft placement and is not an urgent concern.
D. Subclavian dialysis catheter remains in place. This is an expected finding, as the catheter is being used for interim dialysis access.
E. Dressing is dry and intact. This is a normal, reassuring finding indicating no signs of infection or drainage at the site.
H. Intake for past 12 hours 600 mL. This intake alone is not excessive; the concern lies in the overall pattern of weight gain and fluid overload rather than this single intake value.
J. Client reports being very tired. Fatigue is a nonspecific symptom common in ESRD and, while relevant, is not as urgent as the objective signs of fluid overload.
L. Mucous membranes moist. This is a normal, expected finding indicating adequate hydration of mucous membranes.
M. Capillary refill less than 4 seconds. While slightly prolonged, this is an improvement from the earlier finding of greater than 3 seconds and is not the priority concern compared to the more significant signs of fluid overload.
O. Weight 194 pounds (88 kg). This reflects the same information as the weight gain already captured in option F and is not a separate, distinct concern.
The nurse brings a scheduled dose of docusate sodium to a client who has cirrhosis of the liver. The client verbalizes never having had bowel problems and does not need a stool softener. Which action should the nurse take?
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Explain the importance of taking measures to reduce the risk of bleeding.
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Withhold the medication until consulting with the healthcare provider (HCP).
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Document the client's refusal to take the prescribed medication.
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Listen to the client's bowel sounds to determine the need for the medication.
Explanation
Correct Answer: (A) Explain the importance of taking measures to reduce the risk of bleeding. Clients with cirrhosis of the liver are at increased risk for esophageal varices due to portal hypertension. Straining during bowel movements from constipation significantly increases the risk of variceal rupture and life-threatening hemorrhage. The nurse should explain to the client that docusate sodium is prescribed to keep stools soft and prevent straining, which helps reduce the risk of bleeding, an important teaching point that addresses the client's concern while emphasizing the medication's therapeutic purpose.
Why Other Options are Incorrect:
B. Withhold the medication until consulting with the healthcare provider (HCP). This is unnecessary, as the nurse can address the client's concern directly through education without requiring HCP consultation.
C. Document the client's refusal to take the prescribed medication. The client has not explicitly refused the medication, only questioned its necessity; the nurse should first provide education rather than documenting a refusal.
D. Listen to the client's bowel sounds to determine the need for the medication. The medication is prescribed to prevent straining and reduce bleeding risk, not solely based on current bowel sound findings, making this an incomplete rationale for withholding patient education.
A client with acute pancreatitis reports experiencing pain and nausea. Which intervention(s) should the nurse implement? Select all that apply.
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Monitor heart, lung, and kidney functions.
-
Review client's abdominal ultrasound results.
-
Encourage an increased intake of clear oral fluids.
-
Position client in reverse trendelenburg position to better perfuse organs.
-
Notify healthcare provider of serum amylase and lipase levels.
Explanation
Correct Answer: (A, B, E) Monitor heart, lung, and kidney functions; Review client's abdominal ultrasound results; Notify healthcare provider of serum amylase and lipase levels. Acute pancreatitis can lead to systemic complications, including cardiovascular instability, respiratory compromise, and acute kidney injury, making it essential for the nurse to monitor heart, lung, and kidney function closely. Reviewing the client's abdominal ultrasound results helps identify the underlying cause of pancreatitis, such as gallstones, and evaluate the extent of pancreatic involvement. Notifying the healthcare provider of serum amylase and lipase levels is important, as these are key diagnostic markers used to assess the severity and progression of pancreatitis.
Why the other options are incorrect:
C. Encourage an increased intake of clear oral fluids. Clients with acute pancreatitis are typically kept NPO to rest the pancreas and reduce stimulation of pancreatic enzymes, especially in the presence of pain and nausea.
D. Position client in reverse trendelenburg position to better perfuse organs. This positioning is not a standard or indicated intervention for the management of acute pancreatitis symptoms.
A client with chronic kidney disease (CKD) missed dialysis yesterday to attend a funeral. The client's spouse calls the home health nurse and reports that the client is lethargic and hard to arouse. Which instruction is most important for the nurse to provide?
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Check for a thrill and bruit at the client's dialysis access site.
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Ensure that the client avoids salt intake for the rest of the day.
-
Take the client to emergency department (ED).
-
Apply the client's home oxygen.
Explanation
Correct Answer: (C) Take the client to emergency department (ED). A client with CKD who misses a dialysis session is at risk for life-threatening complications from the accumulation of fluid, electrolytes, and metabolic waste products, including severe hyperkalemia and altered mental status, both of which can be reflected in the client's lethargy and difficulty arousing. Given the acute change in mental status, the nurse's most important instruction is to have the client evaluated emergently to prevent further deterioration or cardiac complications.
Why the other options are incorrect:
A. Check for a thrill and bruit at the client's dialysis access site. While access site patency is important, this does not address the client's acute, potentially life-threatening change in mental status.
B. Ensure that the client avoids salt intake for the rest of the day. Dietary modification is not an urgent priority given the client's acute lethargy and altered level of consciousness.
D. Apply the client's home oxygen. There is no indication of respiratory distress or hypoxia in this scenario; the client's presenting concern is altered mental status related to missed dialysis.
A 36-year-old male client is brought to the emergency department (ED) following a fall from a ladder approximately 12 ft (3.6 m) high. Reports falling onto his right side and is experiencing pain in his right arm, hip, and leg. Bruising is evident in the client's right thigh. Client denies losing consciousness or hitting his head. He is obese and is a current smoker, smoking one pack per day. Reports an intermittent productive cough for the past five years. Has an incomplete fracture to the right femur. Surgical consultation has been completed, and the client is being admitted to the orthopedic floor for surgery the following morning.
Nurses' Notes:
1400 — The client is admitted to the orthopedic unit. Initial prescriptions are placed by the healthcare provider (HCP) and an initial assessment and vital signs completed.
Assessment:
- Neurological: Alert and oriented to person, place, time, and situation. Full sensation bilateral lower extremities. Denies numbness and tingling.
- Cardiovascular: Heart sounds normal. Regular rhythm. Left leg 2+ dorsalis pedal pulses and 2+ posterior tibial pulses. Right leg 1+ dorsalis pedal pulses and 1+ posterior tibial pulses. Capillary refill 3 seconds bilateral lower extremities.
- Respiratory: Lung sounds are clear in all fields. No signs of respiratory distress, productive cough.
- Gastrointestinal: Denies nausea, vomiting, and diarrhea. Reported last bowel movement this morning.
- Genitourinary: Indwelling urinary catheter in place. Clear straw colored urine is visible in the catheter bag.
- Musculoskeletal: Full range of motion (ROM) in bilateral ankles. Throbbing pain 6 on a 0 to 10 scale reported in right upper leg. 3+ edema in right lower extremity.
2030 — The client reports throbbing pain 8 on a 0 to 10 scale. Administered hydromorphone 0.5 mg IV push (IVP).
2200 — Acetaminophen 650 mg PO is given for throbbing pain reported 3 on a 0 to 10 scale.
2230 — The client reports throbbing pain 8 on a 0 to 10 scale. Administered hydromorphone 0.5 mg IVP.
Assessment:
- Neurological: Anxious. Full sensation bilateral lower extremities. Denies numbness and tingling.
- Cardiovascular: Heart rhythm normal though tachycardic. Diaphoretic. Left leg 3+ dorsalis pedal pulses and 3+ posterior tibial pulses. Right leg 1+ dorsalis pedal pulses and 1+ posterior tibial pulses. Capillary refill 3 seconds bilateral lower extremities. Petechiae on neck and upper chest.
- Respiratory: Fine crackles left lower lobe. Right lung sounds clear. Tachypneic. Dyspnea with use of accessory muscles.
- Gastrointestinal: Active bowel sounds.
- Genitourinary: Indwelling urinary catheter draining straw colored urine 130 mL output in 4 hours.
2330 — An emergent computed tomography (CT) scan is completed.
Flow Sheet:
- Body mass index (BMI): 32.1 kg/m² (normal 18 to 24.9 kg/m²)
1800: Temperature 99° F (37.2° C) orally; Heart rate 81 beats/minute; Respirations 13 breaths/minute; Blood pressure 118/64 mm Hg; Oxygen saturation 99% on room air; Pain 4 on a 0 to 10 scale, right leg
2200: Temperature 98.7° F (37.1° C) orally; Heart rate 86 beats/minute; Respirations 15 breaths/minute; Blood pressure 126/72 mm Hg; Oxygen saturation 97% on room air; Pain 3 on a 0 to 10 scale, right leg
Orders (1400):
- Bedrest
- Regular diet
- NPO at midnight
- Insert peripheral IV (PIV) catheter and maintain per unit protocol
- Acetaminophen 650 mg PO every 6 hours PRN for mild pain
- Tramadol 50 mg PO every 6 hours PRN for intermediate pain
- Hydromorphone 0.5 mg IV push (IVP) every 2 hours PRN for severe pain
- Place indwelling urinary catheter for immobility
- Report urinary output less than 30 mL/hour
- Titrate oxygen via nasal cannula 1 to 5 L/minute to keep oxygen saturation greater than 92%
Imaging Studies (2330): Computed tomography (CT) chest: Pulmonary edema in right lung and patch distribution of opacities consistent with embolism.
Laboratory Studies — Day 2, 0230:
Arterial Blood Gas:
- pH: 7.30 — Reference range: 7.35 to 7.45
- PaCO2: 36 mm Hg — Reference range: 35 to 45 mm Hg
- HCO3-: 18 mEq/L (18 mmol/L) — Reference range: 22 to 26 mEq/L (22 to 26 mmol/L)
- PaO2: 59 mm Hg — Reference range: 80 to 100 mm Hg
Additional Labs:
- Erythrocyte sedimentation rate: 31 mm/hr — Reference range: Less than 15 mm/hr
- Serum calcium: 8.2 mg/dL (2.05 mmol/L) — Reference range: 9.5 to 10.5 mg/dL (2.25 to 2.62 mmol/L)
- Red blood cell count: 3.5 x 10⁶/μL (3.5 x 10¹²/L) — Reference range: 4.0 to 5.9 x 10⁶/μL (4.0 to 5.9 x 10¹²/L)
- Hemoglobin: 12 g/dL (120 g/L) — Reference range: 14 to 18 g/dL (140 to 180 g/L)
- Hematocrit: 40% (0.40 volume fraction) — Reference range: 42 to 52% (0.42 to 0.52 volume fraction)
- Platelet count: 100,000/mm³ (100 x 10⁹/L) — Reference range: 150,000 to 400,000/mm³ (150 to 400 x 10⁹/L)
Triglycerides: 210 mg/dL (2.37 mmol/L) — Reference range: 40 to 160 mg/dL (0.45 to 1.81 mmol/L)Additional Labs:
The nurse considers which priority treatments are needed for a fat embolus.
Click to indicate if interventions are indicated or not indicated for the treatment of a client with a pulmonary fat embolus. Each row must have only one response option selected.
Order | Indicated | Not indicated Bedrest | ☐ | ☐ Anticoagulation | ☐ | ☐ Fluid hydration | ☐ | ☐ Thrombolytics | ☐ | ☐ Steroid therapy | ☐ | ☐ Oxygenation | ☐ | ☐
-
Bedrest
-
Anticoagulation
-
Fluid hydration
-
Thrombolytics
-
Steroid therapy
-
Oxygenation
Explanation
Bedrest — Indicated
Anticoagulation — Not indicated
Fluid hydration — Indicated
Thrombolytics — Not indicated
Steroid therapy — Indicated
Oxygenation — Indicated
Bedrest is indicated to prevent further fat migration from the fracture site and to reduce metabolic demand while the client stabilizes. Fluid hydration is indicated to maintain hemodynamic stability and support organ perfusion, particularly given this client's tachycardia and evolving respiratory compromise. Steroid therapy is indicated because corticosteroids help reduce the systemic inflammatory response associated with fat embolism syndrome, which may improve outcomes. Oxygenation is indicated and essential given this client's significant hypoxemia, reflected by a PaO2 of 59 mm Hg and an ABG consistent with metabolic acidosis with a compensatory component.
Why the other options are incorrect:
Anticoagulation. Anticoagulants are used to treat blood clot (thromboembolic) emboli, not fat emboli, since fat embolism syndrome is not caused by a clot formation process.
Thrombolytics. Thrombolytic therapy is used to dissolve blood clots and is not effective or indicated for a fat embolus, which is composed of fat globules rather than a fibrin clot.
Nurses' Notes: 1600 — Pupils equal and reactive. Glasgow coma scale 13. 1700 — Pupils equal and reactive. Glasgow coma scale 14. 1800 — Pupils equal and reactive. Glasgow coma scale 13. 1900 — Pupils equal and reactive. Glasgow coma scale 13.
Laboratory Results: Cerebrospinal fluid, culture: Negative (Reference range: Negative).
Flow Sheet:
Intake and Output (I&O):
- 1600: IV fluid intake 100 mL, urine output 64 mL
- 1700: IV fluid intake 100 mL, urine output 59 mL
- 1800: IV fluid intake 100 mL, urine output 337 mL
- 1900: IV fluid intake 100 mL, urine output 421 mL
Vital Signs:
- 1600: Temperature 98.0° F (36.7° C) orally, heart rate 64 beats/minute, respiratory rate 16 breaths/minute, blood pressure 109/63 mm Hg, oxygen saturation 100% on room air
- 1700: Heart rate 69 beats/minute, respiratory rate 14 breaths/minute, blood pressure 111/72 mm Hg, oxygen saturation 100% on room air
- 1800: Heart rate 82 beats/minute, respiratory rate 15 breaths/minute, blood pressure 101/65 mm Hg, oxygen saturation 99% on room air
- 1900: Heart rate 102 beats/minute, respiratory rate 16 breaths/minute, blood pressure 89/51 mm Hg, oxygen saturation 98% on room air
Orders (1200):
- Admit to the intensive care unit
- Vital signs every hour
- Neurological checks every hour
- Infuse 0.9% sodium chloride with 5% dextrose and 20 mEq of potassium chloride solution IV at 100 mL/hr
Imaging Studies (1130): Head computed tomography (CT) scan: No blood or edema noted.
Ready for the question when you'd like to share it.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Actions to Take:
- Implement seizure precautions
- Collect blood to measure serum electrolytes
- Call rapid response
- Bolus intravenous fluids
- Discontinue the 0.9% sodium chloride
Potential Conditions:
- Brain herniation
- Thyrotoxicosis crisis
- Diabetes insipidus
- Syndrome of inappropriate antidiuretic hormone
Parameters to Monitor:
- Potassium
- Strict intake and output
- Daily weight
- Blood pressure
- Apical pulse
-
Implement seizure precautions
-
Collect blood to measure serum electrolytes
-
Call rapid response
-
Bolus intravenous fluids
-
Discontinue the 0.9% sodium chloride
-
Brain herniation
-
Thyrotoxicosis crisis
-
Diabetes insipidus
-
Syndrome of inappropriate antidiuretic hormone
-
Potassium
-
Strict intake and output
-
Daily weight
-
Blood pressure
-
Apical pulse
Explanation
Correct Answer:
- Potential Condition: Diabetes insipidus
- Actions to Take: Collect blood to measure serum electrolytes; Bolus intravenous fluids
- Parameters to Monitor: Strict intake and output; Daily weight
This client is demonstrating a progressive pattern of markedly increasing urine output (64 mL, 59 mL, 337 mL, 421 mL over four hours) alongside rising heart rate and falling blood pressure, indicating a significant fluid volume deficit. In the setting of CNS involvement from viral meningitis, this pattern is most consistent with diabetes insipidus (DI), which occurs when there is insufficient antidiuretic hormone (ADH), causing the kidneys to excrete excessive amounts of dilute urine. The nurse should collect blood to measure serum electrolytes, since DI commonly causes hypernatremia and dehydration from massive free water loss. The nurse should also administer a bolus of intravenous fluids to address the significant fluid volume deficit reflected in the rising urine output, tachycardia, and dropping blood pressure. To assess the client's progress, the nurse should maintain strict intake and output monitoring to track ongoing fluid losses and guide fluid replacement, and obtain daily weights, since weight changes are a sensitive and reliable indicator of overall fluid status.
Why Other Options are Incorrect:
Implement seizure precautions. There is no data indicating seizure activity or risk in this scenario; the client's declining GCS and vital sign changes are more consistent with a fluid and electrolyte disturbance.
Call rapid response. While this client requires close monitoring and intervention, the vital sign trends, though concerning, do not yet indicate an immediate life-threatening emergency requiring rapid response activation.
Discontinue the 0.9% sodium chloride. The current IV fluid should not be discontinued; rather, additional fluid replacement is needed to address the significant volume loss from polyuria.
Brain herniation. This would present with signs such as unequal or nonreactive pupils, significant GCS decline, and Cushing's triad (bradycardia, irregular respirations, widening pulse pressure), none of which are demonstrated in this client's data.
Thyrotoxicosis crisis. There is no clinical indication of thyroid dysfunction in this scenario; the client's presentation is directly related to their CNS infection and fluid status.
Syndrome of inappropriate antidiuretic hormone. SIADH causes fluid retention and decreased urine output due to excess ADH, which is the opposite of this client's presentation of significantly increasing urine output.
Potassium. While potassium is being infused and should be monitored as part of routine care, it is not the primary parameter needed to assess this client's fluid volume status related to DI.
Blood pressure. While relevant, blood pressure is already being monitored hourly per current orders and is not one of the two most specific parameters needed to track fluid balance trends in DI compared to strict I&O and daily weight.
Apical pulse. This is not the priority monitoring parameter for assessing fluid status and progress in the management of diabetes insipidus.
A client who received partial thickness and full thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit. Which IV fluid should the nurse prepare to administer during the acute phase of the client's burn recovery?
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Lactate Ringer's.
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Total parenteral nutrition.
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5% dextrose in water.
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5% dextrose in 0.25 normal saline.
Explanation
Correct Answer: (A) Lactate Ringer's. Lactated Ringer's solution is the standard IV fluid used during the acute (emergent) phase of burn resuscitation. It is an isotonic, balanced electrolyte solution that closely resembles the composition of extracellular fluid, helping to replace the massive fluid losses that occur from capillary leak and third-spacing following extensive burn injury.
Why the other options are incorrect:
B. Total parenteral nutrition. TPN addresses nutritional needs and is not the priority fluid used for emergent fluid resuscitation in the acute phase of burn injury.
C. 5% dextrose in water. This hypotonic solution does not adequately replace lost electrolytes and can cause fluid shifts into cells, worsening cellular edema.
D. 5% dextrose in 0.25 normal saline. This solution is also hypotonic and does not provide the balanced electrolyte replacement needed for burn resuscitation.
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Give IV analgesia.
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Administer tetanus immunization.
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Start IV antibiotics.
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Give an IV bolus of normal saline.
Explanation
Correct Answer: (D) Give an IV bolus of normal saline. Full thickness burns cause massive fluid loss through damaged skin and capillary leak, placing the client at high risk for hypovolemic shock. The priority intervention is to initiate aggressive IV fluid resuscitation with a bolus of normal saline to maintain adequate circulating volume and organ perfusion.
Why Other Options are Incorrect:
A. Give IV analgesia. While pain management is important, it is not the priority over addressing the client's immediate risk for hypovolemic shock from significant fluid loss.
B. Administer tetanus immunization. Tetanus prophylaxis is appropriate for burn wound care but is not the priority intervention in the acute phase compared to fluid resuscitation.
C. Start IV antibiotics. Prophylactic antibiotics are not a priority intervention in the immediate management of burns and are not routinely indicated unless infection is present.
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