Nokea
Daily weights are being recorded for the patient with a urine output that has been less than the intravenous and oral intake. The weight yesterday was 97.5 kg. This morning it is 99 kg. The nurse understands that this corresponds to a(n)
- A. fluid retention of 1.5 liters.
- B. fluid loss of 1.5 liters.
- C. equal intake and output due to insensible losses.
- D. fluid loss of 0.5 liters.
Correct Answer: A
Rationale: The correct answer is A: fluid retention of 1.5 liters. The weight gain from 97.5 kg to 99 kg indicates an increase in fluid retention. This difference of 1.5 kg corresponds to fluid retention of 1.5 liters, as 1 liter of water weighs approximately 1 kg. This weight gain suggests that the patient is retaining more fluid than they are excreting, leading to an increase in weight.
Incorrect choices:
B: fluid loss of 1.5 liters - This is incorrect because the weight increased, indicating fluid retention.
C: equal intake and output due to insensible losses - This is incorrect as weight increased, showing an imbalance in intake and output.
D: fluid loss of 0.5 liters - This is incorrect as the weight increased, indicating fluid retention, not loss.
You may also like to solve these questions
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than the right eyelid. Which description should the nurse use to document this finding?
- A. A nystagmus on the left.
- B. Exophthalmos on the right.
- C. Ptosis on the left eyelid.
- D. Astigmatism on the right.
Correct Answer: C
Rationale: The correct answer is C: Ptosis on the left eyelid. Ptosis refers to drooping of the eyelid, which is a common condition in older adults. In this scenario, the nurse should document the finding as ptosis on the left eyelid because the client's left upper eyelid is drooping, covering more of the iris than the right eyelid.
Explanation: Nystagmus (A) is an involuntary eye movement, not related to eyelid drooping. Exophthalmos (B) is the protrusion of the eyeball and not relevant to this scenario. Astigmatism (D) refers to a refractive error of the eye and does not cause eyelid drooping. Therefore, the correct choice is C as it accurately describes the client's condition.
The critical care unit environment is very stressful for patients, families, and staff. What nursing action is directed at reducing environmental stress?
- A. Constant expert evaluation of patient status
- B. Limiting visits to immediate family
- C. Bathing all patients during hours of sleep
- D. Maintaining a quiet environment during hours of sleep
Correct Answer: D
Rationale: The correct answer is D: Maintaining a quiet environment during hours of sleep. This action is directed at reducing environmental stress in the critical care unit because noise and disturbances during sleep can negatively impact patients' rest and recovery. By ensuring a quiet environment, patients can have uninterrupted sleep, which is crucial for healing.
Rationale:
1. Constant expert evaluation of patient status (A) may be important but does not directly address environmental stress.
2. Limiting visits to immediate family (B) may hinder patients' emotional support and can be stressful for families.
3. Bathing all patients during hours of sleep (C) may disrupt patients' rest and increase stress levels rather than reduce it.
When addressing an ethical dilemma, contextual, physiolo gical, and personal factors of the situation must be considered. Which of the following is an example of a personal factor?
- A. The hospital has a policy that everyone must have an aadbvirba.ncocme/dte sdt irective on the chart.
- B. The patient has lost 20 pounds in the past month and is fatigued all of time.
- C. The patient has expressed their beliefs concerning wha t quality of life means and their wishes.
- D. The primary care provider considers care to be futile in a given situation.
Correct Answer: C
Rationale: The correct answer is C because the patient's expressed beliefs and wishes regarding quality of life are personal factors that directly influence the ethical dilemma. This factor reflects the individual's values, beliefs, and preferences, which are essential in making ethical decisions that respect the patient's autonomy. Considering the patient's beliefs helps healthcare professionals navigate complex ethical situations by aligning the care provided with the patient's values. Choices A, B, and D do not directly relate to personal factors but rather focus on hospital policies, physiological symptoms, and the provider's perspective, respectively. Personal factors are crucial in ethical decision-making as they center on the patient's autonomy and preferences.
The nurse is caring for a patient whose condition has deter iorated and is now not responding to standard treatment. The primary health care provider ca lls for an ethical consultation with the family to discuss potential withdrawal versus aggressivabei rtbr.ceoamtm/teestn t. The nurse understands that applying a model for ethical decision making involves which of the following? (Select all that apply.)
- A. Burden versus benefit
- B. Family’s wishes
- C. Patient’s wishes
- D. Potential outcomes of treatment options
Correct Answer: A
Rationale: The correct answer is A: Burden versus benefit. In ethical decision-making, considering the burden of treatment on the patient versus the potential benefits is crucial. This involves weighing the risks, benefits, and potential harm of treatment options. Family's wishes (B) and patient's wishes (C) are important factors but may not always align with what is ethically best for the patient. Potential outcomes of treatment options (D) are relevant but do not directly address the ethical dilemma of balancing burden and benefit. Therefore, A is the correct choice as it directly relates to the ethical principles guiding decision-making in this scenario.
Which of the following situations may result in a low cardiac output and low cardiac index? (Select all that apply.)
- A. Exercise
- B. Hypovolemia
- C. Myocardial infarction
- D. Shock
Correct Answer: B
Rationale: Certainly. Hypovolemia, or low blood volume, can lead to low cardiac output and cardiac index because the heart has less blood to pump, resulting in reduced circulation. Exercise typically increases cardiac output to meet increased demand. Myocardial infarction may reduce cardiac output temporarily, but not consistently. Shock, a condition where the body's tissues do not receive enough oxygen and nutrients, can lead to low cardiac output, making it a possible cause.