Nokea
. 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.
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A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that do mot apply.)
- A. Electrocardiogram changes
- B. Slow, shallow respirations
- C. Paralytic ileus
- D. Skeletal muscle weakness
Correct Answer: B
Rationale: Correct Answer: B - Slow, shallow respirations
Rationale:
1. Electrolyte imbalance in renal failure often leads to respiratory alkalosis, causing rapid and deep respirations, not slow and shallow.
2. Electrocardiogram changes (A) are common with electrolyte imbalances, particularly potassium and calcium.
3. Paralytic ileus (C) is a complication of electrolyte imbalances, affecting gastrointestinal motility.
4. Skeletal muscle weakness (D) is a common manifestation of electrolyte imbalances, especially potassium and magnesium deficiencies.
Summary:
Choice B is incorrect because slow, shallow respirations are not typically associated with electrolyte imbalances related to renal failure. Choices A, C, and D are commonly seen complications of electrolyte imbalances and should be assessed by the nurse.
. One day after a patient is admitted to the medical unit, you note that the patient is oliguric. You notify the acutecare nurse practitioner who orders a fluid challenge of 200 mL of normal saline solution over
15 minutes. This intervention will achieve which of the following?
- A. Help distinguish hyponatremia from hypernatremia
- B. Help evaluate pituitary gland function
- C. Help distinguish reduced renal blood flow from decreased renal function
- D. Help provide an effective treatment for hypertension-induced oliguria
Correct Answer: C
Rationale: The correct answer is C: Help distinguish reduced renal blood flow from decreased renal function.
Rationale:
1. Oliguria is a decrease in urine output.
2. Fluid challenge with normal saline can help determine the cause of oliguria by assessing the response of the kidneys.
3. If the oliguria improves after the fluid challenge, it suggests reduced renal blood flow as the cause.
4. If oliguria persists, it indicates decreased renal function.
Summary:
A. Fluid challenge does not directly help in distinguishing between hyponatremia and hypernatremia.
B. Evaluating pituitary gland function requires specific tests, not just a fluid challenge.
D. Treating hypertension-induced oliguria may involve different interventions, not just a fluid challenge.
A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
- A. Assess the airway.
- B. Administer prescribed bronchodilators.
- C. Provide oxygen.
- D. Administer prescribed mucolytics
Correct Answer: A
Rationale: The correct answer is A: Assess the airway. The nurse should prioritize airway assessment as the client's ABGs indicate respiratory acidosis (low pH, high PaCO2). This suggests potential airway obstruction or inadequate ventilation. Ensuring a patent airway is crucial for adequate oxygenation. Administering bronchodilators (B) or mucolytics (D) may help with airway clearance but should come after ensuring a clear airway. Providing oxygen (C) is important, but addressing the underlying respiratory acidosis by first assessing the airway is the priority in this situation to prevent further deterioration.
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 nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching?
- A. You will need to wear a sling on your arm while the device is in place
- B. There is no risk of infection because sterile technique will be used during insertion.
- C. . Ask all providers to vigorously clean the connections prior to accessing the device.
- D. You will not be able to take a bath with this vascular access device.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Choice C is correct because it emphasizes the importance of cleaning connections before accessing the device to prevent infection.
2. Sterile technique during insertion cannot guarantee no risk of infection (Choice B).
3. Wearing a sling is unnecessary for a central vascular access device (Choice A).
4. The statement about not being able to take a bath is not accurate and is not a common restriction (Choice D).