Nokea
An older client is receiving an IV of 5% dextrose in 0.45% normal saline at 75 mL/hour. Which assessment finding indicates to the nurse that the client is developing a complication from this therapy?
- A. Capillary refill takes > 3 seconds.
- B. Episodes of vertigo and loss of balance.
- C. Average daily output of 1200 ml.
- D. Pulse rate of 110 beats/minute and dyspnea upon exertion.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
You may also like to solve these questions
A 2-year-old child with laryngotracheobronchitis (LTB) is fussy and restless in the oxygen tent. The oxygen level in the tent is 25%, and blood gases are normal. What would be the correct action by the nurse?
- A. Restrain the child in the tent and notify the health care provider.
- B. Increase the oxygen concentration in the tent.
- C. Take the child out of the tent and into the playroom.
- D. Ask the mother for help in comforting the child.
Correct Answer: B
Rationale: The child with LTB should be placed in the mist tent with 30% oxygen. Restlessness is caused by poor oxygenation. The child should not be taken out of the oxygenated tent. While the mother could be asked to help comfort the child, and the health care provider may be notified, the priority is to set the oxygen at the correct level.
When planning care for a client newly diagnosed with open-angle glaucoma, the nurse identifies a priority nursing problem of visual sensory/perceptual alterations. This problem is based on which etiology?
- A. Limited eye movement.
- B. Decreased peripheral vision.
- C. Blurred distance vision.
- D. Photosensitivity.
Correct Answer: B
Rationale: The correct answer is B: Decreased peripheral vision. In open-angle glaucoma, decreased peripheral vision is a characteristic symptom resulting from increased intraocular pressure. This visual impairment can lead to sensory/perceptual alterations. Choice A, limited eye movement, is not directly associated with the pathophysiology of open-angle glaucoma. Choice C, blurred distance vision, is more commonly seen in conditions like myopia or presbyopia. Choice D, photosensitivity, is not a typical manifestation of open-angle glaucoma and is more commonly associated with conditions like migraines or certain medications.
The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting sputum?
- A. Breathe deeply, followed by swallowing.
- B. Breathe deeply, followed by spitting into a cup.
- C. Breathe deeply, followed by coughing up the sputum.
- D. Breathe deeply, followed by clearing the throat.
Correct Answer: C
Rationale: The correct answer is to instruct the client to breathe deeply followed by coughing up the sputum. This method ensures that the specimen is collected from the lower respiratory tract and is not contaminated by saliva. Choice A (swallowing) does not result in sputum collection, while choice B (spitting into a cup) may lead to saliva contamination. Choice D (clearing the throat) is not an effective way to collect sputum as it may involve getting rid of saliva, not sputum.
When assessing an adolescent with depression, what is the most important question for the nurse to ask?
- A. What is causing your feelings of depression?
- B. Have you ever thought about suicide?
- C. What actions can we take to improve your mood?
- D. Would you like your friends to come over?
Correct Answer: B
Rationale: The correct answer is B: 'Have you ever thought about suicide?' When assessing an adolescent with depression, it is crucial to ask direct questions about suicidal thoughts. This helps determine the severity of the situation, especially if the person has considered or planned to harm themselves. Choice A is not as direct and specific to suicidal ideation. Choice C focuses on improving mood rather than assessing the risk of harm. Choice D is unrelated to assessing suicidal ideation and the severity of the depression.
An adult client who received partial-thickness and full-thickness burns over 40% of the body in a house fire is admitted to the inpatient burn unit.
- A. Normal Saline
- B. Lactated Ringer's
- C. 5% Dextrose in water
- D. 0.45% Sodium Chloride
Correct Answer: B
Rationale: In burn patients, Lactated Ringer's solution is preferred over other options as it helps in restoring fluid and electrolyte balance effectively. Lactated Ringer's contains electrolytes (sodium, potassium, calcium) that closely mimic the body's natural composition, making it a suitable choice for fluid resuscitation in burn injuries. Normal Saline (Choice A) lacks electrolytes like potassium and calcium, which are essential in burn management. 5% Dextrose in water (Choice C) is a hypotonic solution and is not the ideal choice for fluid resuscitation in burn patients. 0.45% Sodium Chloride (Choice D) is a hypotonic solution mainly used for conditions requiring free water replacement rather than volume expansion needed in burn injuries.