Nokea
A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;
- A. 13 gtt/min
- B. 29 gtt/min
- C. 16 gtt/min
- D. 32 gtt/min Situation 5: Protection of self and patient can be done by supporting the body's immunity.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When assessing the external ear, the nurse palpates a small protrusion of the helix called a Darwin tubercle. The nurse would document this finding as which of the following?
- A. A normal finding
- B. An abnormal finding
- C. A normal finding only in the older adult
- D. An abnormal finding only in the older adult
Correct Answer: A
Rationale: A Darwin tubercle is a small, painless, hereditary nodule located on the helix of the ear. It is a normal anatomical variation and is present in varying degrees in the general population, regardless of age. Therefore, it would be documented as a normal finding during the assessment of the external ear.
A 62-year old client diagnosed with pyelonephritis and possible septicemia has had five urinary tract infections over the past 2 years. She's fatigued from lack of sleep; urinates frequently, even during the night, and has lost weight recently. Tests reveal the following: sodium level 152mEq/L, osmolarity 340mOsm/L, glucose level 125mg/dl, and potassium level of 3.8mEq/L. Which of the following nursing diagnoses is most appropriate for this client?
- A. Deficient fluid volume related to inability to conserve water
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolic state
- C. Deficient fluid volume related to osmotic diuresis induced by hypernatremia
- D. Imbalanced nutrition: Less than body requirements related to catabolic effects of insulin deficiency
Correct Answer: C
Rationale: The client's elevated sodium level of 152 mEq/L indicates hypernatremia, which can lead to osmotic diuresis, causing excessive urination and subsequent fluid loss. This fluid loss can result in deficient fluid volume. The client's symptoms of frequent urination, fatigue from lack of sleep, and weight loss are indicative of dehydration due to the osmotic diuresis. Therefore, the most appropriate nursing diagnosis for this client is Deficient fluid volume related to osmotic diuresis induced by hypernatremia.
which of the following is the primary objective of care for the child with nephrosis?
- A. reduce blood pressure.
- B. reduce excretion of urinary protein.
- C. increase excretion of urinary protein.
- D. increase ability of tissues to retain fluid.
Correct Answer: B
Rationale: The primary objective of care for a child with nephrosis, also known as nephrotic syndrome, is to reduce the excretion of urinary protein. Nephrosis is a condition characterized by excessive loss of protein through the urine, leading to hypoalbuminemia and edema. By reducing the excretion of urinary protein, healthcare providers aim to minimize protein loss and improve the child's nutritional status and overall health. This can be achieved through medications such as corticosteroids, diuretics, and other treatments that help to decrease proteinuria and manage symptoms associated with nephrosis. Additionally, dietary modifications and monitoring for complications such as infection and thrombosis are important aspects of care for children with nephrosis.
The nurse is caring for a patient receiving warfarin therapy. Which of the following findings is essential to report to the physician?
- A. Bleeding time 3 (normal = 2-5 sec) c.PTT 29 (normal = 30-45 sec)
- B. INR 4 (normal = 2-3 sec)
- C. PT 20 (normal = 9-12 sec)
Correct Answer: B
Rationale: An INR of 4 is higher than the normal therapeutic range for patients receiving warfarin therapy, which is typically between 2-3. An INR value above the therapeutic range indicates that the patient is at an increased risk of bleeding complications. Therefore, it is essential to report this finding to the physician for further evaluation and possible adjustment of the warfarin dosage to prevent excessive bleeding. The other values provided (A and C) are within or close to the normal ranges, so they would not warrant immediate concern compared to the elevated INR level.
Nurse Beverly is giving preoperative instructions to Ian who is scheduled for an Ileostomy. Which of the following would be included?
- A. "Your urine will be collected in a pouch following surgery."
- B. "You will have a nasogastric tube after surgery."
- C. "Your bowel will be visualized with a laparoscope during surgery."
- D. "You can drink liquids within 24 hours after surgery."
Correct Answer: A
Rationale: An ileostomy is a surgical procedure that involves creating a stoma from the ileum (part of the small intestine) to the abdominal wall, allowing waste to bypass the colon and exit the body through the stoma into a pouch worn on the outside of the body. Therefore, it is important for Nurse Beverly to inform Ian that his stool output will be collected in a pouch following the surgery. Option A is the correct choice as it directly relates to the postoperative care and management specific to an ileostomy procedure.