Nokea
1.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure?
- A. Lower the extremity below the level of the heart.
- B. Apply warm compresses to the extremity.
- C. Tap the skin lightly and avoid slapping.
- D. Place a washcloth between the skin and tourniquet
Correct Answer: D
Rationale: The correct answer is D: Place a washcloth between the skin and tourniquet. This step helps protect the client's skin by providing a barrier between the tourniquet and the skin, reducing the risk of skin irritation or damage. Lowering the extremity below the heart (A) can increase venous pressure and make it harder to insert the catheter. Warm compresses (B) can dilate blood vessels and increase the risk of bruising. Tapping the skin lightly (C) can irritate the skin and is unnecessary for skin protection.
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The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation.
What diagnosis could the patient have that could cause inadequate ventilation?
- A. Endocarditis
- B. Multiple myeloma
- C. Guillain-Barr syndrome
- D. Overdose of amphetamines
Correct Answer: C
Rationale: Rationale: Guillain-Barr syndrome can cause inadequate ventilation due to paralysis of the respiratory muscles. This results in respiratory acidosis. Endocarditis, multiple myeloma, and amphetamine overdose do not directly affect ventilation. Endocarditis is an infection of the heart valves, multiple myeloma is a cancer of plasma cells, and amphetamine overdose primarily affects the central nervous system and cardiovascular system, not ventilation. Therefore, Guillain-Barr syndrome is the most likely diagnosis in this case.
You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the followin
- A. Diminished deep tendon reflexes
- B. Tachycardia
- C. Cool, clammy skin
- D. Acute flank pain
Correct Answer: A
Rationale: Step 1: High magnesium levels can lead to hypermagnesemia, which can cause decreased neuromuscular function.
Step 2: Diminished deep tendon reflexes are a sign of neuromuscular impairment, indicating potential hypermagnesemia.
Step 3: Assessing for diminished deep tendon reflexes is crucial to monitor neuromuscular function in patients with high magnesium levels.
Summary: A is correct because hypermagnesemia affects neuromuscular function. B, C, and D are incorrect as they do not directly relate to the effects of high magnesium levels.
A client with a serum potassium of 7.5 mEq/L and cardiovascular changes needs immediate intervention. Which prescription should the nurse implement first?
- A. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth.
- B. Provide a heart-healthy, low-potassium diet.
- C. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
- D. Prepare the client for hemodialysis treatment.
Correct Answer: C
Rationale: The correct answer is C. The client's high serum potassium level of 7.5 mEq/L can lead to serious cardiovascular complications like arrhythmias. The immediate priority is to lower potassium levels rapidly to prevent cardiac arrest. Administering dextrose 20% and regular insulin IV push helps shift potassium from extracellular to intracellular space, lowering serum levels quickly. Option A (Kayexalate) is not as rapid as insulin therapy. Option B (low-potassium diet) is not immediate. Option D (hemodialysis) is effective but not as quick as insulin therapy for urgent potassium reduction.
A patient with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Increased PaCO2
- D. CNS disturbances
Correct Answer: B
Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation leads to excessive elimination of carbon dioxide, causing a decrease in PaCO2 levels, resulting in respiratory alkalosis. This is the most common cause of hyperventilation. Respiratory acidosis (choice A) occurs when there is retention of carbon dioxide. Increased PaCO2 (choice C) is a consequence of respiratory acidosis, not alkalosis. CNS disturbances (choice D) can lead to abnormal breathing patterns but are not the most common cause of hyperventilation.
. A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his
home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to
light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of
urine is present. What is the nurses most likely explanation for the low urine output?
- A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept
in place.
- B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
- C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in
decreased urine output. - D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that
results in diminished urine output.
Correct Answer: D
Rationale: The correct answer is D. The man's elevated heart rate, anxiety, and low urine output indicate a sympathetic reaction. This reaction stimulates the renin-angiotensin-aldosterone system, leading to decreased urine output. The sympathetic response triggers the release of renin, which activates angiotensin II and aldosterone, causing vasoconstriction and water reabsorption in the kidneys, ultimately reducing urine output. Choice A is incorrect because low urine output is not solely due to urinating before arrival. Choice B is incorrect as there is no indication of traumatic brain injury or ADH deficiency. Choice C is incorrect as atrial natriuretic peptide in heart failure typically increases urine output.