Nokea
The nurse in the postoperative unit prepares to receive a client after a balloon angioplasty of the carotid artery. Which of the ff items of priority should the nurse keep at the bedside for such client?
- A. Blood pressure apparatus
- B. IV infusion stand
- C. Call bell
- D. Endotracheal intubation
Correct Answer: A
Rationale: Rationale:
1. A: Blood pressure apparatus is essential to monitor for any signs of bleeding or clot formation after carotid angioplasty.
2. B: IV infusion stand is important but not the priority for immediate postoperative monitoring.
3. C: Call bell is important for the client to call for assistance but not the priority for immediate postoperative care.
4. D: Endotracheal intubation is not necessary after a carotid angioplasty and is not a priority item for bedside care.
Summary: Monitoring blood pressure is crucial for detecting complications post carotid angioplasty. IV stand, call bell, and endotracheal intubation are important but not the priority in this scenario.
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When teaching a client about insulin administration, the nurse should include which instruction?
- A. “Administer insulin after the first meal of the day.”
- B. “Inject insulin at a 45-degree angle into the deltoid muscle.”
- C. “Shake the insulin vial vigorously before withdrawing the medication.”
- D. “Draw up clear insulin first when mixing two types of insulin in one syringe.”
Correct Answer: D
Rationale: The correct answer is D because drawing up clear insulin first when mixing two types of insulin in one syringe prevents contamination. Clear insulin is drawn up first to avoid clouding from the cloudy insulin. This ensures accurate dosing and prevents potential medication errors.
A: Incorrect. Administering insulin after the first meal may lead to hypoglycemia if the client skips or delays meals.
B: Incorrect. Insulin should not be injected into the deltoid muscle as it can lead to inconsistent absorption rates.
C: Incorrect. Vigorously shaking the insulin vial can cause bubbles, affecting the accuracy of the dose and potentially altering its effectiveness.
Following a unilateral adrenalectomy, the nurse would assess for hyperkalemia shown by which of the following?
- A. Muscle weakness
- B. Diaphoresis
- C. Tremors
- D. Constipation
Correct Answer: A
Rationale: The correct answer is A: Muscle weakness. After unilateral adrenalectomy, there is a risk of hyperkalemia due to decreased aldosterone production. Aldosterone helps regulate potassium levels in the body. Muscle weakness is a common symptom of hyperkalemia as high potassium levels can affect muscle function. Diaphoresis, tremors, and constipation are not typically associated with hyperkalemia. Diaphoresis is excessive sweating, tremors are involuntary muscle movements, and constipation is difficulty passing stool. These symptoms are not directly related to potassium imbalance.
What should the client at risk for developing AIDS be advised to do?
- A. Abstain from anal intercourse
- B. Have a semen analysis done
- C. Have an ELISA test for antibodies
- D. Inform all sexual contacts
Correct Answer: C
Rationale: The correct answer is C because an ELISA test for antibodies is crucial to detect HIV infection early. This test can help diagnose HIV before symptoms appear, allowing for early intervention and treatment. Choice A is important but not specific to HIV prevention. Choice B is irrelevant for HIV prevention. Choice D, while important, should not take precedence over getting tested for HIV.
An adult is receiving total parenteral nutrition. The nurse knows which of the following assessments is essential?
- A. Evaluation of the peripheral venous site
- B. Confirmation that the tube is in the stomach
- C. Assessment of the GI tract, including bowel sounds
- D. Fluid and electrolyte monitoring
Correct Answer: D
Rationale: The correct answer is D: Fluid and electrolyte monitoring. In total parenteral nutrition (TPN), monitoring fluid and electrolyte balance is crucial to prevent complications like dehydration, electrolyte imbalances, and overload. Regular assessment ensures the patient's stability and prevents potential adverse effects. Option A (Evaluation of the peripheral venous site) is important but not essential compared to maintaining fluid and electrolyte balance. Option B (Confirmation that the tube is in the stomach) is irrelevant for a patient receiving TPN as it bypasses the GI tract. Option C (Assessment of the GI tract, including bowel sounds) is not necessary as TPN is given intravenously, bypassing the GI tract altogether.
A patient with abnormal sodium losses is receiving a house diet. To provide 1,600mg sodium daily, the nurse could supplement the patient’s diet with:
- A. One beef cube and 8oz of tomato juice
- B. One beef cube and 16oz of tomato juice
- C. Four beef cubes and 8oz of tomato juice
- D. One beef cube and 12oz tomato juice
Correct Answer: D
Rationale: The correct answer is D because 1 beef cube contains about 1,000mg of sodium. To reach 1,600mg, the patient needs an additional 600mg. 12oz of tomato juice contains approximately 600mg of sodium, making it the right choice.
A: Not enough sodium from the beef cube and tomato juice.
B: Too much sodium from the 16oz of tomato juice.
C: Too much sodium from the 4 beef cubes.