Nokea
.A nurse assesses a clients peripheral IV site, and notices edema and tenderness above the site. Which action should the nurse take next?
- A. Apply cold compresses to the IV site.
- B. Elevate the extremity on a pillow.
- C. Flush the catheter with normal saline.
- D. . Stop the infusion of intravenous fluids.
Correct Answer: D
Rationale: The correct action is to stop the infusion of intravenous fluids. Edema and tenderness above the IV site suggest infiltration, where fluid leaks into surrounding tissues. Stopping the infusion prevents further damage and helps prevent complications. Applying cold compresses (A) may not address the underlying issue. Elevating the extremity (B) is helpful for other conditions like swelling due to dependent edema, not infiltration. Flushing the catheter (C) can exacerbate the issue by pushing more fluid into the tissue.
You may also like to solve these questions
When planning the care of a patient with a fluid imbalance, the nurse understands that in the human body, water
and electrolytes move from the arterial capillary bed to the interstitial fluid. What causes this to occur?
- A. Active transport of hydrogen ions across the capillary walls
- B. Pressure of the blood in the renal capillaries
- C. Action of the dissolved particles contained in a unit of blood
- D. Hydrostatic pressure resulting from the pumping action of the heart
Correct Answer: D
Rationale: Rationale: The correct answer is D. Hydrostatic pressure resulting from the pumping action of the heart causes water and electrolytes to move from the arterial capillary bed to the interstitial fluid. This occurs due to the force exerted by the heart's pumping action, pushing fluid out of the capillaries into the interstitial space. This process is known as filtration and is essential for maintaining fluid balance in the body.
Summary of other choices:
A: Active transport of hydrogen ions does not directly cause the movement of water and electrolytes between capillaries and interstitial fluid.
B: The pressure in renal capillaries specifically relates to the kidneys, not the general movement of water and electrolytes in the body.
C: The dissolved particles in blood do not directly contribute to the movement of water and electrolytes between capillaries and interstitial fluid.
You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease.
What principle should guide your assessment of the patients skin turgor?
- A. Overhydration is common among healthy older adults.
- B. Dehydration causes the skin to appear spongy
- C. Inelastic skin turgor is a normal part of aging
- D. Skin turgor cannot be assessed in patients over 70.
Correct Answer: C
Rationale: The correct answer is C: Inelastic skin turgor is a normal part of aging. As people age, their skin loses elasticity and becomes less turgid, which can affect skin turgor assessment. Skin turgor assessment is an important indicator of hydration status, and in older adults, it is normal for the skin to be less elastic. This is due to changes in collagen and elastin fibers in the skin with aging. Choices A, B, and D are incorrect because overhydration is not common among healthy older adults, dehydration causes the skin to appear tented rather than spongy, and skin turgor can still be assessed in patients over 70, although it may be less reliable due to natural changes in skin elasticity with aging.
You are called to your patients room by a family member who voices concern about the patients status. On
assessment, you find the patient tachypnic, lethargic, weak, and exhibiting a diminished cognitive ability. You also
find 3+ pitting edema. What electrolyte imbalance is the most plausible cause of this patients signs and symptoms?
- A. Hypocalcemia
- B. Hyponatremia
- C. Hyperchloremia
- D. Hypophosphatemia
Correct Answer: C
Rationale: The correct answer is C: Hyperchloremia. In this scenario, the patient's symptoms point towards fluid overload, which can lead to hyperchloremia due to excessive chloride intake. 3+ pitting edema suggests fluid retention, a common symptom of hyperchloremia. Additionally, tachypnea can occur as a compensatory mechanism for metabolic acidosis seen in hyperchloremia. Lethargy, weakness, and diminished cognitive ability can be attributed to electrolyte imbalances impacting nerve and muscle function.
Choice A: Hypocalcemia is less likely as it typically presents with neuromuscular irritability, not lethargy.
Choice B: Hyponatremia usually presents with neurological symptoms like confusion and seizures, not the symptoms described.
Choice D: Hypophosphatemia typically presents with muscle weakness, not the full constellation of symptoms described.
You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You
and your colleague note that the patients labs indicate minimally elevated serum creatinine levels, which your
colleague dismisses. What can this increase in creatinine indicate in older adults?
- A. Substantially reduced renal function
- B. Acute kidney injury
- C. Decreased cardiac output
- D. ) Alterations in ratio of body fluids to muscle mass
Correct Answer: A
Rationale: The correct answer is A: Substantially reduced renal function. In older adults, elevated serum creatinine levels can indicate impaired kidney function, as the kidneys may not filter waste products as efficiently. This can lead to a buildup of creatinine in the blood. Acute kidney injury (Choice B) is a sudden decline in kidney function and would typically present with a more significant increase in creatinine levels. Decreased cardiac output (Choice C) would not directly cause elevated creatinine levels. Alterations in the ratio of body fluids to muscle mass (Choice D) would not be a common cause of elevated creatinine levels in this scenario.
A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?
- A. Do you take any over-the-counter medications?
- B. You appear anxious. What is causing your distress?
- C. Do you have a history of anxiety attacks?
- D. You are breathing fast. Is this causing you to feel light-headed?
Correct Answer: B
Rationale: The correct answer is B: "You appear anxious. What is causing your distress?" because hyperventilation can be triggered by emotional distress or anxiety. By addressing the underlying cause of the hyperventilation, the nurse can provide appropriate interventions to help the client manage their anxiety and subsequently reduce the hyperventilation episodes.
A: "Do you take any over-the-counter medications?" - This question is not directly related to addressing the client's anxiety or distress, which is the primary concern in hyperventilation.
C: "Do you have a history of anxiety attacks?" - While relevant to understanding the client's medical history, this question does not address the immediate cause of hyperventilation in this specific situation.
D: "You are breathing fast. Is this causing you to feel light-headed?" - This question focuses on the physical symptoms of hyperventilation rather than exploring the emotional or psychological triggers, which are essential in managing hyperventilation caused by anxiety.