Nokea
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
- A. Hypotension
- B. Distended neck veins
- C. Slow capillary refill
- D. Weak, thready pulse
Correct Answer: B
Rationale: The correct answer is B: Distended neck veins. When a client has fluid volume excess, there is an accumulation of fluid in the intravascular space, leading to increased venous pressure. Distended neck veins are a classic sign of fluid overload as they indicate increased central venous pressure. Hypotension (A) is more commonly associated with fluid volume deficit. Slow capillary refill (C) and weak, thready pulse (D) are indicative of poor tissue perfusion, which is more commonly seen in fluid volume deficit rather than excess.
You may also like to solve these questions
What is the primary focus of the Triple Aim in healthcare?
- A. Improving patient experience
- B. Reducing healthcare costs
- C. Improving population health
- D. Ensuring regulatory compliance
Correct Answer: A
Rationale: The primary focus of the Triple Aim in healthcare is to improve patient experience, which encompasses quality, safety, and satisfaction. This approach aims to enhance care delivery, promote patient-centeredness, and optimize outcomes. Reducing healthcare costs and improving population health are important aspects but are secondary to enhancing the patient experience. Ensuring regulatory compliance is crucial but not the primary objective of the Triple Aim framework. Thus, choice A is correct as it aligns with the core principle of prioritizing the needs and preferences of patients for better overall healthcare outcomes.
The complexities of the current health care delivery systems require a variety of leadership styles. Which of the following leadership styles would be most effective in this environment?
- A. Autocratic leadership
- B. Laissez-faire leadership
- C. Transactional leadership
- D. Transformational leadership
Correct Answer: D
Rationale: The correct answer is D: Transformational leadership. In the current health care environment, transformational leadership is most effective as it focuses on inspiring and motivating individuals to achieve a common goal through innovation and vision. This style encourages creativity, adaptability, and collaboration, which are essential in navigating the complexities of the health care delivery systems. Transformational leaders empower their team members, foster a culture of continuous improvement, and drive positive change. Autocratic leadership (A) is too controlling, Laissez-faire leadership (B) lacks direction and accountability, and Transactional leadership (C) focuses on rewards and punishments rather than inspiring and developing individuals.
A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching?
- A. The patient always carries hard candies when engaging in exercise.
- B. The patient goes for a vigorous walk when his glucose is 200 mg/dL.
- C. The patient has a peanut butter sandwich before going for a bicycle ride.
- D. The patient increases daily exercise when ketones are present in the urine.
Correct Answer: D
Rationale: The correct answer is D. Increasing exercise when ketones are present can worsen diabetic ketoacidosis. A patient should not exercise with ketones in urine. Carrying candies for exercise (A) helps manage low blood sugar. Going for a walk with a glucose of 200 mg/dL (B) can help lower blood sugar. Eating a sandwich before exercise (C) provides fuel.
An RN’s client with terminal pancreatic cancer asks questions about a do not resuscitate order. Which of the following statements should be included in the RN’s teaching to the client?
- A. When a heart ceases to beat, the client is pronounced clinically dead.
- B. Physicians must write do not resuscitate (DNR) orders.
- C. A DNR order can be written after the health-care provider has discussed it with the client and family.
- D. A DNR requires a court decision.
Correct Answer: C
Rationale: Rationale for Correct Answer C:
1. In terminal cases, it's crucial for the healthcare provider to discuss DNR orders with the client and family to ensure understanding and consent.
2. The decision to implement a DNR order should always involve the client and their family to respect their wishes.
3. This statement emphasizes the importance of communication and shared decision-making in end-of-life care.
Summary:
A: Incorrect - This statement is about the clinical definition of death, not about DNR orders.
B: Incorrect - While physicians can write DNR orders, the involvement of the client and family is essential.
D: Incorrect - DNR orders do not require a court decision; they are typically based on the client's wishes and discussions with healthcare providers.
A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?
- A. Lispro (Humalog)
- B. Glargine (Lantus)
- C. Detemir (Levemir)
- D. NPH (Humulin N)
Correct Answer: A
Rationale: The correct answer is A: Lispro (Humalog). Lispro is a rapid-acting insulin that is ideal for mealtime coverage in intensive insulin therapy because it mimics the body's natural insulin response after a meal, providing quick and effective blood sugar control. Lispro has a rapid onset of action, peaks quickly, and has a shorter duration of action compared to other types of insulin. This makes it suitable for covering the rise in blood sugar levels that occurs after meals.
Summary of why other choices are incorrect:
B: Glargine (Lantus) is a long-acting insulin used for basal coverage, not for mealtime coverage.
C: Detemir (Levemir) is an intermediate-acting insulin used for basal coverage, not for mealtime coverage.
D: NPH (Humulin N) is an intermediate-acting insulin with a slower onset and longer duration of action, making it less suitable for mealtime coverage in intensive insulin therapy.