Nokea
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.
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The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?
- A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone.
- B. Observe for swelling of the neck, tracheal deviation, and severe pain.
- C. Evaluate the quality of the patient's voice postoperatively, noting any drastic changes.
- D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.
Correct Answer: D
Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia.
A nurse sees a variety of patients in the community health clinic. Which of the following patients would be at the greatest risk of dehydration?
- A. An 18-year-old basketball player with a stress fracture of the right foot
- B. An infant with diarrhea
- C. A 45-year-old with stomach flu
- D. An elderly patient living alone
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A patient's lab results show a slight decrease in potassium. The physician has declined to treat with drug therapy but has suggested increasing the potassium through diet. Which of the following would be a good source of potassium?
- A. Apples
- B. Asparagus
- C. Carrots
- D. Bananas
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is admitting a patient with a suspected fluid imbalance. The most sensitive indicator of body fluid balance is:
- A. Daily weight
- B. Serum sodium levels
- C. Measured intake and output
- D. Blood pressure
Correct Answer: A
Rationale: Daily weights show trends and can assist medical management by indicating if interventions and medications are effective. Laboratory data are objective data that indicate whether electrolyte levels are within normal limits for the patient with fluid balance problems. However, if a patient is dehydrated, some laboratory data can show false elevations. Intake and output is extremely important, but matching the two is difficult because fluid is also lost through breathing, perspiration, stool, and surgical tubes. Vital signs may or may not be helpful because heart rate and blood pressure can be elevated by either depletion or excess of fluids in some situations.
A patient who is in renal failure partially loses the ability to regulate changes in pH because the kidneys:
- A. Regulate and reabsorb carbonic acid to change and maintain pH
- B. Buffer acids through electrolyte changes
- C. Regenerate and reabsorb bicarbonate to maintain a stable pH
- D. Combine carbonic acid and bicarbonate to maintain a stable pH
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.