Nokea
After a Whippie procedure for cancer of the pancreas, a client is to receive the following intravenous (IV) fluids over 24 hours; 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. The nurse calculates that the clients IV fluid intake Tor 24 hours will be:
- A. 3150ml
- B. 3650 ml
- C. 3200 ml
- D. 3750ml
Correct Answer: D
Rationale: The correct answer is D (3750ml) because the client will receive 1000ml D5W + 500ml normal saline + 1500ml D5NS + 50ml antibiotic every 8 hours x 3 times in 24 hours (50ml x 3 = 150ml). Adding these together gives a total of 1000ml + 500ml + 1500ml + 150ml = 3150ml. Therefore, the client's IV fluid intake for 24 hours will be 3150ml.
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Which blood product replaces missing clotting factors in the patient who has a bleeding disorder?
- A. Platelets
- B. Albumin
- C. Packed RBC
- D. Cryoprecipitate
Correct Answer: D
Rationale: The correct answer is D: Cryoprecipitate. Cryoprecipitate contains high levels of clotting factors such as fibrinogen, Factor VIII, Factor XIII, and von Willebrand factor, making it the ideal choice to replace missing clotting factors in patients with bleeding disorders. Platelets (A) help with clot formation but do not contain clotting factors. Albumin (B) is a protein used for volume replacement, not clotting factor replacement. Packed RBC (C) is used to increase oxygen-carrying capacity in anemic patients, not for clotting factor replacement.
A 40 year-old female nurse had a fecal impaction and was admitted to the hospital. The physician orders an oil retention enema followed by a cleansing enema. What is the rationale for administering the oiul enema first?
- A. lubricate the walls of the intestinal tract
- B. soften the fecal mass and lubricate the walls of the rectum and colon
- C. reduce bacterial content of the fecal mass
- D. coat the walls of the intestines to prevent irritation by the hardened fecal mass
Correct Answer: B
Rationale: The correct answer is B: soften the fecal mass and lubricate the walls of the rectum and colon. First, the oil retention enema helps soften the fecal mass, making it easier to pass. Second, the oil lubricates the walls of the rectum and colon, reducing friction and making the passage of stool smoother. This helps prepare the fecal impaction for removal during the subsequent cleansing enema. Choices A, C, and D are incorrect because they do not directly address the primary goal of softening the fecal mass and lubricating the walls of the intestines to facilitate the removal of the impaction.
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D: Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Rationale:
1. Establish rapport: Asking about usual sleep patterns shows empathy and builds rapport.
2. Holistic assessment: Understanding sleep patterns helps identify potential issues beyond the leg cast.
3. Gather information: Knowing the onset of sleep difficulty can reveal underlying causes.
4. Patient-centered care: Addressing sleep concerns aligns with patient needs.
Incorrect answers:
A: Focusing solely on the leg and cast disregards the patient's holistic well-being.
B: Documenting without addressing the patient's concern neglects the opportunity for intervention.
C: Delaying assessment till the next shift can worsen the patient's condition and delay appropriate care.
A nurse is assisting with lunch at a nursing home. Suddenly, one of the residents begins to choke and is unable to breathe. The nurse assesses the resident’s ability to breathe and then begins CPR. Why did the nurse assess respiratory status?
- A. To identify a life-threatening problem
- B. To establish a database for medical care
- C. To practice respiratory assessment skills
- D. To facilitate the resident’s ability to breathe
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Assessing respiratory status is crucial during a choking incident to identify if the resident is unable to breathe.
2. In this scenario, the resident's inability to breathe indicates a life-threatening problem requiring immediate intervention.
3. CPR is initiated based on the assessment of the resident's breathing difficulty, emphasizing the critical nature of identifying a life-threatening issue.
4. The assessment of respiratory status directly informs the nurse's actions to address the immediate danger of choking.
Summary:
- Choice A is correct as assessing respiratory status helps identify life-threatening issues like choking.
- Choice B is incorrect as the primary focus is on immediate intervention, not establishing a database.
- Choice C is incorrect as the assessment is not for skill practice but for identifying a critical situation.
- Choice D is incorrect as the goal is not to facilitate breathing but to address the immediate life-threatening problem.
A patient with a new diagnosis of lymphoma is experiencing fatigue. Which of the ff. is the best way to assess her fatigue?
- A. Observe her activity level
- B. Have her rate her fatigue on a scale of 0 to
- C. Monitor for changes in vital signs 10
- D. Monitor hemoglobin and hematocrit values
Correct Answer: B
Rationale: The correct answer is B because having the patient rate her fatigue on a scale allows for a subjective assessment directly from the patient, providing valuable insight into the severity and impact of fatigue on her daily life. This approach considers the patient's perspective, which is crucial in understanding her experience and tailoring interventions.
Choice A (observing activity level) may not accurately capture the subjective experience of fatigue. Choice C (monitoring vital signs) does not directly assess fatigue but rather general health status. Choice D (monitoring hemoglobin and hematocrit values) can indicate anemia but may not fully capture the patient's fatigue experience.