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A patient is kept off food and fluids for 10 hours before surgery. His oral temperature at 8 a.m. is 99.8°F (37.7°C). This temperature reading probably indicates:
- A. Infection
- B. Hypothermia
- C. Anxiety
- D. Dehydration
Correct Answer: D
Rationale: A patient being kept off food and fluids before surgery can lead to dehydration. Dehydration can cause a slight increase in body temperature, which could explain the elevated oral temperature reading of 99.8°F (37.7°C) in this scenario. Infections are more likely to cause higher fevers, hypothermia would present with a lower temperature, and anxiety typically does not directly affect body temperature in this manner.
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Which of the following conditions may necessitate fluid restriction?
- A. Fever
- B. Chronic Obstructive Pulmonary Disease
- C. Renal Failure
- D. Dehydration
Correct Answer: C
Rationale: Renal failure often necessitates fluid restriction to prevent fluid overload. In renal failure, the kidneys are unable to effectively filter and excrete excess fluids, leading to fluid accumulation in the body. Restricting fluid intake helps manage this condition by preventing further fluid buildup and complications such as edema and electrolyte imbalances.
Mrs. Mitchell has been given a copy of her diet. The nurse discusses the foods allowed on a 500-mg low sodium diet. These include:
- A. A ham and Swiss cheese sandwich on whole wheat bread
- B. Mashed potatoes and broiled chicken
- C. A tossed salad with oil and vinegar and olives
- D. Chicken bouillon
Correct Answer: B
Rationale: The correct answer is B: Mashed potatoes and broiled chicken. Both mashed potatoes and broiled chicken are typically low in sodium content, making them suitable choices for a 500-mg low sodium diet. The other options, such as a ham and Swiss cheese sandwich on whole wheat bread, a tossed salad with oil and vinegar and olives, and chicken bouillon, may contain higher amounts of sodium and are not typically recommended for a low sodium diet.
What is the appropriate needle size for insulin injection?
- A. 18G, 1 ½" long
- B. 22G, 1" long
- C. 22G, 1 ½" long
- D. 25G, 5/8" long
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler's position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?
- A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
- B. Place a humidifier in the patient's room
- C. Continue administering oxygen by high humidity face mask
- D. Perform chest physiotherapy on a regular schedule
Correct Answer: D
Rationale: Chest physiotherapy is the most effective intervention in cases of impaired gas exchange related to increased secretions. This technique helps mobilize and clear secretions from the airways, thereby improving gas exchange in the lungs. Placing a humidifier or administering oxygen by high humidity face mask may provide moisture but may not directly address the clearance of secretions. Encouraging increased fluid intake can help with hydration but may not address the underlying issue of impaired gas exchange due to secretions.
If a patient's blood pressure is 150/96, what is his pulse pressure?
- A. 54
- B. 96
- C. 150
- D. 246
Correct Answer: A
Rationale: Pulse pressure is calculated by subtracting the diastolic pressure from the systolic pressure. In this case, the systolic pressure is 150 and the diastolic pressure is 96. Therefore, the pulse pressure is 150 - 96 = 54. Pulse pressure represents the force generated by the heart with each contraction and is an important indicator of cardiovascular health.