Nokea
A patient's peripheral parenteral nutrition (PN) bag is nearly empty, and a new PN bag has not arrived yet from the pharmacy. Which intervention by the nurse is appropriate?
- A. Monitor the patient's capillary blood glucose every 6 hours.
- B. Infuse 5% dextrose in water until a new PN bag is delivere
- D. Decrease the PN infusion rate to 10 mL/hr until a new bag arrives.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Infusing 5% dextrose in water will provide the patient with necessary calories and prevent hypoglycemia until the new PN bag arrives.
2. Dextrose infusion will help maintain glucose levels and prevent metabolic complications.
3. Monitoring capillary blood glucose every 6 hours (Choice A) may not provide immediate support to prevent hypoglycemia.
4. Decreasing the PN infusion rate (Choice D) may lead to inadequate nutrition and compromise patient's metabolic needs.
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After abdominal surgery, your patient has a severe coughing episode that causes wound evisceration. In addition to calling the doctor, which intervention is most appropriate?
- A. Irrigate the wound & organs with Betadine
- B. Cover the wound with a saline-soaked sterile dressing.
- C. Apply a dry sterile dressing & binder
- D. Push the organs back & cover with moist sterile dressings.
Correct Answer: B
Rationale: The correct answer is B: Cover the wound with a saline-soaked sterile dressing. This intervention helps maintain a moist environment for wound healing and prevents further contamination. Irrigating with Betadine (A) can be harmful to tissues. Applying a dry sterile dressing (C) can lead to desiccation and delays healing. Pushing organs back (D) should only be done by a medical professional to avoid causing further harm.
Which information in this male patient's electronic health record as shown in the accompanying figure will the nurse use to confirm that the patient has metabolic syndrome? (Select all that apply.)
- A. Weight
- B. Waist size
- C. Blood glucose
- D. Blood pressure
Correct Answer: B
Rationale: The correct answer is B: Waist size. The nurse can confirm metabolic syndrome by assessing waist size as it is a key component in diagnosing the condition. Metabolic syndrome is characterized by central obesity, which is reflected in an increased waist circumference. The other choices, weight (A), blood glucose (C), and blood pressure (D), may provide valuable information in assessing the patient's overall health but are not specific indicators of metabolic syndrome. Weight alone does not necessarily indicate central obesity, blood glucose may be elevated due to other reasons, and blood pressure can be affected by various factors unrelated to metabolic syndrome. Therefore, waist size is the most relevant measure to confirm the presence of metabolic syndrome in this case.
Which of the following cells produce hydrochloric acid?
- A. parietal cells
- B. enteroendocrine cells
- C. mucous neck cells
- D. chief cells
Correct Answer: A
Rationale: The correct answer is A: parietal cells. Parietal cells are located in the gastric glands of the stomach and are responsible for producing hydrochloric acid to help with digestion. They also secrete intrinsic factor, which is essential for vitamin B12 absorption. Enteroendocrine cells (B) produce hormones, mucous neck cells (C) secrete mucus to protect the stomach lining, and chief cells (D) produce pepsinogen for protein digestion, but they do not produce hydrochloric acid. Therefore, parietal cells are the only cells among the choices that specifically produce hydrochloric acid.
A nurse admits a client to the emergency department who reports nausea and vomiting that worsens when he lies down. Antacids do not help. The provider suspects acute pancreatitis. Which of the following laboratory test results should the nurse expect to see?
- A. Decreased WBC
- B. Increased serum amylase
- C. Decreased serum lipase
- D. Increased serum calcium
Correct Answer: B
Rationale: The correct answer is B: Increased serum amylase. In acute pancreatitis, the pancreas becomes inflamed and releases enzymes like amylase into the bloodstream. Amylase levels rise significantly in this condition. Elevated serum amylase is a key diagnostic marker for acute pancreatitis.
A: Decreased WBC - This is not a typical finding in acute pancreatitis. Inflammation in the pancreas usually leads to an increased WBC count.
C: Decreased serum lipase - Lipase levels actually increase in acute pancreatitis along with amylase. Both are important diagnostic markers.
D: Increased serum calcium - While hypercalcemia can occur in severe pancreatitis, it is not as specific or sensitive as elevated amylase levels in diagnosing acute pancreatitis.
Folds in the mucosa of the stomach are called _ which allows the surface area to _.
- A. Crypt, Increase
- B. Rugae, Increase
- C. Rugae, Decrease
- D. Crypt, Decrease
Correct Answer: B
Rationale: The correct answer is B: Rugae, Increase. Rugae are folds in the mucosa of the stomach that allow for expansion of the stomach when food is ingested, increasing the surface area for digestion and absorption. Rugae help in mixing and breaking down food efficiently.
Explanation:
1. Rugae are specifically found in the stomach to increase surface area for digestion.
2. The folds of rugae help in stretching the stomach to accommodate food intake.
3. Increased surface area aids in better absorption of nutrients.
4. Crypts are invaginations in the mucosa but not related to increasing surface area.
5. Option C and D are incorrect because rugae actually increase, not decrease, the surface area of the stomach.