Nokea
A pregnant client with hypertension and cardiac dysrhythmias is admitted to the hospital. Which of the following imbalances should the nurse check for?
- A. Metabolic acidosis
- B. Hypernatremia
- C. Hypomagnesemia
- D. Hypercalcemia
Correct Answer: C
Rationale: The correct answer is C: Hypomagnesemia.
1. Hypertension and cardiac dysrhythmias can be exacerbated by low magnesium levels.
2. Magnesium plays a crucial role in maintaining normal heart rhythm and blood pressure.
3. Hypomagnesemia can lead to cardiac arrhythmias and worsen hypertension.
4. Metabolic acidosis (A) is not directly related to hypertension and dysrhythmias.
5. Hypernatremia (B) and hypercalcemia (D) are less likely to be associated with cardiac issues in this context.
In summary, checking for hypomagnesemia is essential due to its direct impact on the client's hypertension and cardiac dysrhythmias.
You may also like to solve these questions
The most common buffer system in the body is the:
- A. Plasma protein buffer system
- B. Phosphate buffer system
- C. Hemoglobin buffer system
- D. Bicarbonate-carbonic system
Correct Answer: D
Rationale: The correct answer is D, the bicarbonate-carbonic system. This buffer system is crucial in maintaining the body's pH balance. When CO2 combines with water in the blood, it forms carbonic acid, which dissociates into bicarbonate ions and hydrogen ions. Bicarbonate acts as a base, accepting excess hydrogen ions to prevent a decrease in pH. Hemoglobin and plasma proteins primarily function as transport molecules, not as buffer systems. Phosphate buffer system is present in intracellular fluids, not as commonly in the body. The bicarbonate-carbonic system is the most prevalent buffer system in the blood and plays a vital role in regulating blood pH.
A client with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U- 100 regular insulin and 35 U of 100-U isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
- A. “Inject insulin into healthy tissue with large blood vessels and nerves.”
- B. “Rotate injection sites within the same anatomic region, not among different regions.”
- C. “Administer insulin into areas of scar tissue or hypotrophy whenever possible.”
- D. “Administer insulin into sites above muscles that you plan to exercise heavily later that day.”
Correct Answer: B
Rationale: The correct answer is B: “Rotate injection sites within the same anatomic region, not among different regions.” This instruction is important to prevent lipodystrophy and ensure consistent insulin absorption. Rotating sites within the same region helps maintain consistent insulin absorption rates and reduces the risk of developing scar tissue or fatty deposits. Injecting into healthy tissue with large blood vessels and nerves (choice A) can lead to inconsistent absorption. Administering insulin into areas of scar tissue or hypotrophy (choice C) can also disrupt absorption. Injecting into sites above muscles planned for exercise (choice D) can lead to unpredictable insulin absorption. Rotation within the same region optimizes insulin delivery and prevents complications.
Which of the ff nursing interventions should a nurse perform when caring for a client with congestive heart failure who has decreased cardiac output?
- A. Encourage activities that engage the Valsalva maneuver
- B. Encourage the client to perform exercises
- C. Assess apical heart before administering digitalis
- D. Offer small frequent feedings
Correct Answer: C
Rationale: The correct answer is C: Assess apical heart before administering digitalis. This is important because digitalis can slow down the heart rate, so it is crucial to monitor the client's heart rate before giving the medication to prevent further decrease in cardiac output. Encouraging activities that engage the Valsalva maneuver (A) is contraindicated in clients with congestive heart failure as it can lead to increased intra-thoracic pressure and decreased venous return, worsening cardiac output. Encouraging the client to perform exercises (B) may also increase cardiac workload and exacerbate symptoms. Offering small frequent feedings (D) is generally beneficial for clients with congestive heart failure to prevent overeating and promote easier digestion, but it does not directly address the decreased cardiac output concern in this scenario.
Which question would be most appropriate for a nurse to ask a patient to assist in establishing a nursing diagnosis of Diarrhea?
- A. “What types of foods do you think caused your upset stomach?”
- B. “How many bowel movements a day have you had?”
- C. “Are you able to get to the bathroom in time?”
- D. “What medications are you currently taking?”
Correct Answer: B
Rationale: The correct answer is B because asking about the frequency of bowel movements is crucial in assessing diarrhea, a common symptom. This information helps determine the severity and duration of the condition, guiding the nurse in identifying potential causes and appropriate interventions. Choice A focuses on the cause of upset stomach, not specifically diarrhea. Choice C is more related to incontinence rather than diarrhea. Choice D is important but not directly related to establishing a nursing diagnosis for diarrhea. Therefore, Choice B is the most appropriate question to assist in accurately assessing and diagnosing diarrhea.
A client with end-stage acquired immunodeficiency syndrome (AIDS) has profound manifestations of Cryptosporidium infection caused by the protozoa. In planning the client’s care, the nurse should focus on his need for:
- A. Pain management
- B. Antiretroviral therapy
- C. Fluid replacement
- D. High-calorie intake
Correct Answer: C
Rationale: The correct answer is C: Fluid replacement. In end-stage AIDS with Cryptosporidium infection, the client experiences severe diarrhea leading to dehydration and electrolyte imbalances. Fluid replacement is crucial to prevent hypovolemia and maintain electrolyte balance. Adequate hydration supports renal function, prevents further complications, and aids in the elimination of the infectious agent. Pain management (A) may be needed for discomfort but is not the priority. Antiretroviral therapy (B) is essential for managing HIV but does not directly address the immediate issue of dehydration. High-calorie intake (D) is important for overall nutrition but does not address the urgent need for fluid replacement in this situation.