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A nurse educator is reviewing peripheral IV insertion with a group of novice nurses. How should these nurses be
encouraged to deal with excess hair at the intended site?
- A. Leave the hair intact
- B. Shave the area.
- C. Clip the hair in the area.
- D. Remove the hair with a depilatory.
Correct Answer: C
Rationale: The correct answer is C: Clip the hair in the area. Clipping the hair is the most appropriate option as it reduces the risk of infection during IV insertion by minimizing the presence of bacteria that may be trapped in the hair. Shaving (B) can cause micro-abrasions leading to increased infection risk. Leaving the hair intact (A) can also trap bacteria. Using a depilatory (D) can cause skin irritation and should be avoided. In summary, clipping the hair is the best option to maintain a clean and safe environment for IV insertion.
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After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?
- A. . I dont drink milk because it gives me gas and diarrhea
- B. I have been taking digoxin every day for the last 15 years
- C. . I take sodium bicarbonate after every meal to prevent heartburn
- D. In hot weather, I sweat so much that I drink six glasses of water each day.
Correct Answer: C
Rationale: The correct answer is C because taking sodium bicarbonate after every meal can actually increase the risk of metabolic alkalosis due to its alkaline nature. Sodium bicarbonate can lead to an excessive build-up of bicarbonate in the bloodstream, causing alkalosis.
Choice A is not directly related to metabolic alkalosis. Choice B, taking digoxin, is unrelated to metabolic alkalosis as well. Choice D, drinking six glasses of water due to sweating, does not contribute to metabolic alkalosis as it helps maintain hydration and electrolyte balance.
A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that do not apply.)
- A. Increased pulse rate
- B. . Distended neck veins
- C. Warm and pink skin
- D. Skeletal muscle weakness
Correct Answer: C
Rationale: Step 1: Fluid overload leads to increased fluid volume in the body, causing skin to appear pale, cool, and clammy due to poor circulation.
Step 2: "Warm and pink skin" is not a typical manifestation of fluid overload.
Step 3: Therefore, the correct answer is C.
Summary:
A: Increased pulse rate - Possible in fluid overload due to increased volume causing increased workload on the heart.
B: Distended neck veins - Common in fluid overload due to increased venous pressure.
C: Warm and pink skin - Incorrect, as skin is usually pale, cool, and clammy.
D: Skeletal muscle weakness - Not directly related to fluid overload.
You are the surgical nurse caring for a 65-year-old female patient who is postoperative day 1 following a
thyroidectomy. During your shift assessment, the patient complains of tingling in her lips and fingers. She tells you that
she has an intermittent spasm in her wrist and hand and she exhibits increased muscle tone. What electrolyte imbalance
should you first suspect?
- A. Hypophosphatemia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Hypocalcemia. Following a thyroidectomy, there is a risk of damaging the parathyroid glands, leading to hypocalcemia. Symptoms such as tingling in lips and fingers, muscle spasms, and increased muscle tone are classic signs of hypocalcemia. The initial concern should be hypocalcemia due to its potential to cause serious complications such as tetany and laryngospasm. Options A, C, and D are incorrect as they do not align with the symptoms described. Hypophosphatemia may present with weakness and respiratory failure, hypermagnesemia with hypotension and respiratory depression, and hyperkalemia with muscle weakness and cardiac arrhythmias.
. A medical nurse educator is reviewing a patients recent episode of metabolic acidosis with members of the
nursing staff. What should the educator describe about the role of the kidneys in metabolic acidosis?
- A. The kidneys retain hydrogen ions and excrete bicarbonate ions to help restore balance.
- B. The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance
- C. The kidneys react rapidly to compensate for imbalances in the body
- D. The kidneys regulate the bicarbonate level in the intracellular fluid.
Correct Answer: B
Rationale: Correct Answer: B - The kidneys excrete hydrogen ions and conserve bicarbonate ions to help restore balance.
Rationale:
1. In metabolic acidosis, the blood pH is low due to excess acid in the body.
2. To restore pH balance, the kidneys excrete hydrogen ions (acid) and conserve bicarbonate ions (a base).
3. By excreting acid and retaining base, the kidneys help neutralize the excess acid in the body.
4. Option B accurately describes the role of the kidneys in metabolic acidosis.
Incorrect Choices:
A: Incorrect. The kidneys do not retain hydrogen ions in metabolic acidosis; they excrete them.
C: Incorrect. While the kidneys do play a role in correcting imbalances, they do not react rapidly in metabolic acidosis.
D: Incorrect. The kidneys do regulate bicarbonate levels, but this is not the primary action in metabolic acidosis.
A patient who is being treated for pneumonia starts complaining of sudden shortness of breath. An arterial
blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg.
What does the ABG reflect?
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Metabolic acidosis
Correct Answer: A
Rationale: The correct answer is A: Respiratory acidosis. A low pH (7.21) indicates acidosis. The elevated PaCO2 (64 mm Hg) indicates respiratory acidosis, as high CO2 levels lead to carbonic acid formation, decreasing pH. The normal HCO3 (24 mm Hg) suggests compensation for the respiratory acidosis. Other choices are incorrect as they do not align with the ABG values provided. Metabolic alkalosis (B) would have a high pH and HCO3, respiratory alkalosis (C) would have a high pH and low PaCO2, and metabolic acidosis (D) would have a low pH and HCO3.