Nokea
A patient is admitted who has had severe vomiting for 24 hours. She states that she is exhausted and weak. The results of an admitting ECG show flat T waves and ST segment depression. Choose the most likely potassium (K ) value for this patient.
- A. 4.0mEq/L
- B. 2.0mEq/L
- C. 8.0mEq/L
- D. 2.6mEq/L
Correct Answer: B
Rationale: The patient is displaying signs of hypokalemia (low potassium levels) due to severe vomiting. Symptoms of hypokalemia can include weakness, fatigue, and ECG changes such as flat T waves and ST segment depression. The potassium level that is most likely associated with these symptoms is 2.0mEq/L. Severe vomiting can lead to significant loss of potassium from the body, causing these abnormalities. It is important to address and correct the potassium imbalance to prevent further complications.
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Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?
- A. Restrict fluid intake
- B. Ensure that the client avoids prolonged sitting
- C. Position lower extremities below level of heart
- D. Instruct the client to avoid leg exercises
Correct Answer: C
Rationale: When caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion, it is important to promote optimal blood flow to the tissues. Positioning the lower extremities below the level of the heart helps to facilitate venous return and improve circulation to the extremities. This position helps reduce the workload on the heart and promotes better perfusion to the tissues, ultimately aiding in the prevention of complications related to ineffective tissue perfusion. The other options (A. Restrict fluid intake, B. Ensure that the client avoids prolonged sitting, D. Instruct the client to avoid leg exercises) are not directly related to improving tissue perfusion and may not be appropriate interventions in this situation.
When administering an I.M. injection to an infant, the nurse in charge should use which site?
- A. Deltoid
- B. Dorsogluteal
- C. Ventrogluteal
- D. Vastus lateralis
Correct Answer: D
Rationale: When administering an intramuscular (I.M.) injection to an infant, the nurse should use the vastus lateralis muscle. This is the preferred site for infants as it provides a large muscle mass and is less likely to damage nerves and blood vessels compared to other sites. The vastus lateralis is located on the thigh and is easily accessible for injections in infants. It is important to select the appropriate site for I.M. injections in infants to ensure proper medication absorption and minimize the risk of complications.
The following are warning signs of cancer. Which one is not?
- A. Change In bladder and bowel habits
- B. Weight gain
- C. Indigestion or difficulty in swallowing
- D. Nagging cough or hoarseness
Correct Answer: B
Rationale: Weight gain is not typically considered a warning sign of cancer. In fact, unexplained weight loss is more commonly associated with certain types of cancer. The other options all relate to symptoms that could potentially be warning signs of cancer and are worth discussing with a healthcare professional for further evaluation.
A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient's plan of care?
- A. Deficient fluid volume
- B. Imbalanced nutrition more than body requirements
- C. Excess fluid volume
- D. Noncompliance
Correct Answer: C
Rationale: The patient's symptoms of recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs are indicative of fluid volume excess. These signs and symptoms suggest that the patient is retaining too much fluid, leading to the edema and congestion in the lungs. The nursing diagnosis of Excess Fluid Volume is appropriate for this patient as it reflects the patient's current physiological state and guides the plan of care to address excess fluid accumulation through interventions such as diuretic therapy, fluid restriction, and monitoring of intake and output. Deficient fluid volume, Imbalanced nutrition more than body requirements, and Noncompliance are not appropriate nursing diagnoses given the patient's presentation of fluid overload.
Which of the following types of translocation of childhood AML that typically associated with granulocytic sarcoma mass?
- A. inv(16)
- B. t(8;21)
- C. t(6;9)
- D. inv(3)
Correct Answer: A
Rationale: The inv(16) translocation is strongly associated with granulocytic sarcoma in AML.