Nokea
A patient has a parenteral nutrition infusion of 25% dextrose. A student nurse asks the nurse why a peripherally inserted central catheter was inserted. Which response by the nurse is most appropriate?
- A. There is a decreased risk for infection when 25% dextrose is infused through a central line.
- B. The prescribed infusion can be given much more rapidly when the patient has a central line.
- C. The 25% dextrose is hypertonic and will be more rapidly diluted when given through a central line.
- D. The required blood glucose monitoring is more accurate when samples are obtained from a central line.
Correct Answer: C
Rationale: The 25% dextrose solution is hypertonic. Shrinkage of red blood cells can occur when solutions with dextrose concentrations greater than 10% are administered IV. Blood glucose testing is not more accurate when samples are obtained from a central line. The infection risk is higher with a central catheter than with peripheral IV lines. Hypertonic or concentrated IV solutions are not given rapidly.
You may also like to solve these questions
The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?
- A. Rubber-free toys, such as wooden building blocks, are good choices for the child.
- B. Only foil balloons will be used for the child's birthday party.
- C. A diet of healthy fruits, such as bananas and kiwis, is best for the child.
- D. An epinephrine auto-injector will be on hand to treat allergic reactions.
Correct Answer: C
Rationale: The correct answer is C. Bananas and kiwis are foods that can cross-react with latex allergy, indicating that the parents need further teaching on managing latex allergies. Choices A, B, and D are correct as rubber-free toys, using foil balloons, and having an epinephrine auto-injector are appropriate measures to prevent and manage allergic reactions in a child with a latex allergy.
A patient who has been receiving diuretic therapy is admitted to the emergency department with a serum potassium level of 3.0 mEq/L. The nurse should alert the healthcare provider immediately that the patient is on which medication?
- A. Oral digoxin (Lanoxin) 0.25 mg daily
- B. Ibuprofen (Motrin) 400 mg every 6 hours
- C. Metoprolol (Lopressor) 12.5 mg orally daily
- D. Lantus insulin 24 U subcutaneously every evening
Correct Answer: A
Rationale: The correct answer is A. Hypokalemia increases the risk for digoxin toxicity, which can lead to serious dysrhythmias. Therefore, with a low potassium level, the nurse should immediately alert the healthcare provider about the patient being on oral digoxin. Choices B, C, and D do not pose as much concern with the given potassium level. However, further assessment is still required for these medications.
Spironolactone (Aldactone), an aldosterone antagonist, is prescribed for a patient. Which statement by the patient indicates that the teaching about this medication has been effective?
- A. I will try to drink at least 8 glasses of water every day.
- B. I will use a salt substitute to decrease my sodium intake.
- C. I will increase my intake of potassium-containing foods.
- D. I will drink apple juice instead of orange juice for breakfast.
Correct Answer: D
Rationale: The correct answer is D. Spironolactone is a potassium-sparing diuretic, so patients should choose low-potassium foods. Apple juice is a better choice than orange juice in this case as it is lower in potassium. Option A is incorrect because increasing fluid intake excessively is not necessary. Option B is incorrect as salt substitutes are high in potassium, which should be avoided. Option C is incorrect because patients on spironolactone should avoid increasing their potassium intake.
The father of an 11-year-old client reports to the nurse that the client has been wetting the bed since the passing of his mother and is concerned. Which action is most important for the nurse to take?
- A. Reassure the father that it is normal for a pre-teen to wet the bed during times of stress
- B. Inform the father that nocturnal emissions are abnormal and his son is developmentally delayed
- C. Inform the father that it is most important to let the son know that bedwetting is normal after trauma
- D. Refer the father and the client to a psychologist
Correct Answer: D
Rationale: It is common for children to experience bedwetting as a response to severe trauma, such as losing a parent. Referring the father and the client to a psychologist is crucial in this situation to help the child cope with the loss and address any underlying emotional issues. Choice A is incorrect as bedwetting in this context is likely related to the trauma rather than puberty. Choice B is incorrect as nocturnal emissions are not abnormal and do not relate to bedwetting. Choice C is incorrect because the focus should be on addressing the emotional impact of the trauma rather than specifically discussing bedwetting.
An older adult patient who is malnourished presents to the emergency department with a serum protein level of 5.2 g/dL. The nurse would expect which clinical manifestation?
- A. Pallor
- B. Edema
- C. Confusion
- D. Restlessness
Correct Answer: B
Rationale: The correct answer is B: Edema. The normal range for total protein is 6.4 to 8.3 g/dL. Low serum protein levels cause a decrease in plasma oncotic pressure and allow fluid to remain in interstitial tissues, causing edema. Confusion, restlessness, and pallor are not associated with low serum protein levels. Pallor is more commonly seen in anemia, confusion and restlessness may be related to other issues like electrolyte imbalances or neurological conditions.