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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: C
Rationale: To calculate the total IV fluid intake for 24 hours, we will add up the volume of each type of fluid ordered.
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Nurse Lina gives discharge instructions to Aling Maria, who is experiencing an exacerbation of COPD because of an upper respiratory tract infection, regarding her diet at home. Which of the following food choices would be appropriate?
- A. low fat low cholesterol
- B. low sodium diet
- C. bland soft diet
- D. high calorie high protein
Correct Answer: D
Rationale: A patient experiencing an exacerbation of COPD, especially due to an infection, requires a diet that is high in calories and protein. This is because during exacerbations, the body's energy requirements increase due to increased work of breathing and inflammation. High-calorie intake helps provide the necessary energy for breathing and healing. Additionally, a high-protein diet is important for maintaining respiratory and skeletal muscle strength, which can be affected during exacerbations of COPD. Therefore, a high-calorie high-protein diet would be most appropriate for Aling Maria to support her recovery and overall health during this period.
Why does the nurse instruct the client to avoid Valsalva maneuvers?
- A. Clients BP will decrease momentarily
- B. Client may lose consciousness
- C. Client may suffer from a myocardial
- D. Clients BP will increase momentarily infarction
Correct Answer: C
Rationale: The nurse instructs the client to avoid Valsalva maneuvers because the client may suffer from a myocardial infarction. The Valsalva maneuver involves forcefully trying to exhale against a closed airway, which can increase intra-thoracic pressure and subsequently increase blood pressure. This can lead to an increased workload on the heart, potentially causing myocardial ischemia or infarction in individuals with underlying heart conditions. Therefore, it is important to avoid Valsalva maneuvers, especially in clients at risk for cardiovascular issues.
Which of the ff nursing interventions is required when caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion?
- A. Restrict fluid intake
- B. Ensure that the client avoids prolonged sitting
- C. Position lower extremities below level of heart
- D. Instruct the client to avoid leg exercises
Correct Answer: C
Rationale: When caring for a client after cardiac surgery who is at risk for ineffective tissue perfusion, it is important to promote optimal blood flow to the tissues. Positioning the lower extremities below the level of the heart helps to facilitate venous return and improve circulation to the extremities. This position helps reduce the workload on the heart and promotes better perfusion to the tissues, ultimately aiding in the prevention of complications related to ineffective tissue perfusion. The other options (A. Restrict fluid intake, B. Ensure that the client avoids prolonged sitting, D. Instruct the client to avoid leg exercises) are not directly related to improving tissue perfusion and may not be appropriate interventions in this situation.
A client seeks medical evaluation for fatigue, night sweats, and a 20-lb weight loss in 6 weeks. To confirm that the client has been infected with the human immunodeficiency virus (HIV), the nurse expects the physician to order:
- A. E-rosette immunofluorescence
- B. Enzyme-linked immunosorbent assay
- C. Quantification of T-lymphocytes (ELISA)
- D. Western blot test with ELISA
Correct Answer: D
Rationale: The confirmatory test for HIV infection is a Western blot test. However, before a Western blot test is conducted, an initial screening test with high sensitivity, such as the enzyme-linked immunosorbent assay (ELISA), is typically performed. ELISA is used to detect the presence of HIV antibodies in the blood. If the ELISA test is positive, a Western blot test is then performed to confirm the presence of specific HIV antibodies. The Western blot test is a more specific test for HIV antibodies and is used to confirm the diagnosis. Therefore, in this case, the physician would most likely order a Western blot test following a positive ELISA test to confirm the client's HIV infection.
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: Cryoprecipitate is a blood product that contains concentrated amounts of clotting factors, including fibrinogen, Factor VIII, Factor XIII, and von Willebrand factor. These clotting factors are essential for the formation of blood clots, and when a patient has a bleeding disorder such as hemophilia or von Willebrand disease, cryoprecipitate is used to replace the missing or deficient clotting factors. Platelets are used to help with clot formation in cases of thrombocytopenia, albumin is used to treat low albumin levels in conditions like liver disease, and packed RBCs are used to treat anemia by providing oxygen-carrying red blood cells. However, for a patient with a bleeding disorder needing replacement of missing clotting factors, cryoprecipitate is the most appropriate blood product.