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A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that ¢â‚¬Å“she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.¢â‚¬ The nurse explains to the woman that:
- A. She will need to have her medications adjusted and be readmitted to the hospital for a complete workup.
- B. Limiting fluids can create imbalances in the body that can result in confusion; maybe we need to adjust the timing of your fluids.
- C. It is normal to be a little confused following surgery and it safe not to urinate at night.
- D. Confusion following surgery is common in the elderly due to loss of sleep.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?
- A. Place the patient in low Fowler's and notify the physician.
- B. Increase the patient's IV fluid and auscultate the lungs.
- C. Place the patient in semi-Fowler's and prepare to give the PRN diuretic as ordered.
- D. Discontinue the patient's IV.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would the nurse interpret the results?
- A. Respiratory acidosis with no compensation
- B. Metabolic alkalosis with a compensatory alkalosis
- C. Metabolic acidosis with no compensation
- D. Metabolic acidosis with a compensatory respiratory alkalosis
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart 'flutters' frequently. What action should the nurse take?
- A. Tell the patient to rest more often.
- B. Tell the patient to stop taking the digoxin, and call the physician.
- C. Call the physician, report the symptoms, and request to draw a blood sample to determine the patient's potassium level.
- D. Tell the patient to avoid foods that contain caffeine.
Correct Answer: C
Rationale: Furosemide is a potassium-wasting diuretic. A low potassium level may cause weakness and palpitations. Telling the patient to rest more often won't help the patient if she's hypokalemic. Digoxin isn't causing the patient's symptoms, so she doesn't need to stop taking it. The patient should probably avoid caffeine, but this wouldn't resolve potassium depletion.
A nurse in the medical-surgical unit has a newly admitted patient who is oliguric; the acute care nurse practitioner orders a fluid challenge of 100 to 200 mL of normal saline solution over 15 minutes. The nurse is aware this intervention will help:
- A. Distinguish hyponatremia from hypernatremia
- B. Evaluate pituitary gland function
- C. Distinguish reduced renal blood flow from decreased renal function
- D. Provide an effective treatment for hypertension-induced oliguria
Correct Answer: C
Rationale: If a patient is not excreting enough urine, the health care provider needs to determine whether the depressed renal function is the result of reduced renal blood flow, which is a fluid Volume deficit (FVD) or prerenal azotemia, or acute tubular necrosis that results in necrosis or cellular death from prolonged FVD. A typical example of a fluid challenge involves administering 100 to 200 mL of normal saline solution over 15 minutes. The response by a patient with FVD but normal renal function is increased urine output and increased blood pressure.
A nurse is taking care of a 65-year-old female patient in a medical-surgical unit who is in renal failure; during the assessment the patient complains of tingling in her lips and fingers. When the nurse takes her blood pressure, she has a spasm in her wrist and hand. The nurse suspects:
- A. Hypophosphatemia
- B. Hypocalcemia
- C. Hypermagnesemia
- D. Hyperkalemia
Correct Answer: B
Rationale: Tetany is the most characteristic manifestation of hypocalcemia and hypomagnesemia. Sensations of tingling may occur in the tips of the fingers, around the mouth, and less commonly in the feet. Taking a normal blood pressure could illicit a carpal spasm if it creates slight ischemia of the ulnar nerve.