Nokea
For a client with low blood volume, what are the implications of decreasing blood pressure and a rapid heart rate?
- A. Compression of blood vessels due to blood loss
- B. Increase in the circulating blood volume
- C. Inadequate renal perfusion
- D. Hypovolemia and shock
Correct Answer: D
Rationale: The correct answer is D: Hypovolemia and shock.
Rationale:
1. Low blood volume leads to decreased blood pressure and rapid heart rate as compensatory mechanisms.
2. These signs indicate inadequate perfusion due to reduced blood volume.
3. Hypovolemia can progress to shock if not addressed promptly.
Summary:
A: Compression of blood vessels is not directly related to low blood volume.
B: Increasing circulating blood volume would not occur in a client with low blood volume.
C: Inadequate renal perfusion is a consequence of hypovolemia, not an implication of decreasing blood pressure and rapid heart rate.
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Which instruction about insulin administration should the nurse give to a client?
- A. “Always follow the same order when drawing the different insulin into the syringe.”
- B. “Shake the vial before withdrawing the insulin.”
- C. “Store unopened vials of insulin in the freezer at temperatures well below freezing.”
- D. “Discard the intermediate-acting insulin if it disappears cloudy.”
Correct Answer: A
Rationale: The correct answer is A because maintaining consistency in the order of drawing different types of insulin into the syringe helps prevent medication errors. When mixing insulins, drawing them in the same sequence ensures the correct dose and prevents contamination.
Explanation:
A: Following the same order ensures accurate dosing and minimizes the risk of mixing up insulins.
B: Shaking the vial can cause air bubbles which can affect the accuracy of the dose.
C: Storing insulin in the freezer can damage the medication and alter its effectiveness.
D: Cloudiness in intermediate-acting insulin is normal and does not indicate it should be discarded.
. A client is prescribed prednisone (Deltasone) daily. Which statement best explains why the nurse should instruct the client to take this drug in the morning?
- A. Taking the drug at the same time every day establishes a regular routine, reducing the risk of forgetting a dose.
- B. Prednisone has a longer half-life with morning administration, making it more effective.
- C. Morning administration of prednisone mimics the body’s natural corticosteroid secretion pattern.
- D. Prednisone is best absorbed when taken on an empty stomach first thing in the morning.
Correct Answer: C
Rationale: The correct answer is C because morning administration of prednisone mimics the body's natural corticosteroid secretion pattern. Cortisol, a natural corticosteroid, is typically highest in the morning and decreases throughout the day. By taking prednisone in the morning, the client aligns the drug's peak concentration with the body's natural cortisol levels, optimizing its therapeutic effects.
Choice A is incorrect because while taking the drug at the same time daily is important for consistency, it does not specifically address the rationale for morning administration. Choice B is incorrect as the effectiveness of prednisone is not solely dependent on its half-life but also on alignment with the body's natural rhythm. Choice D is also incorrect as prednisone can be taken with food and does not necessarily require an empty stomach for optimal absorption.
Aling Iska, a 78-year old client consults with a hemoglobin and hematocrit levels of 11mg/dl and 32 % respectively. These finding indicates:
- A. nothing because these are normal findings
- B. the nurse should conduct a thorough nutritional assessment
- C. understanding that the client should be advised to have the test repeated in three months
- D. understanding that anemia is a part of the degeneration of the bone marrow
Correct Answer: B
Rationale: Rationale: Answer B is correct because a hemoglobin level of 11mg/dl and hematocrit level of 32% in a 78-year-old client are indicative of anemia. Conducting a thorough nutritional assessment is essential to identify potential causes of anemia such as iron deficiency or vitamin deficiencies. This assessment will help determine appropriate interventions to manage the anemia.
Summary:
A: Incorrect. These levels are indicative of anemia, not normal findings.
C: Incorrect. Advising to repeat the test in three months may delay necessary interventions for the anemia.
D: Incorrect. While anemia can be related to bone marrow degeneration, a nutritional assessment is needed to identify the specific cause in this case.
Which of the following statements would be the nurse's response to a famiiy member asking questions about a client's transient ischemic attack (TIA)?
- A. "I think you should ask the doctor. Would you like me to cail him for you?"
- B. " The blood supply to the brain has decreased causing permanent brain damage."
- C. "It Is a temporary interruption in the blood flow to the brain."
- D. "TIA means a transient ischemic attack."
Correct Answer: C
Rationale: The correct answer is C because it accurately defines a transient ischemic attack (TIA) as a temporary interruption in blood flow to the brain. This response demonstrates the nurse's knowledge and ability to provide accurate information to the family member.
Option A is incorrect because it deflects the question to the doctor without providing any information. Option B is incorrect because it inaccurately states that TIA causes permanent brain damage, which is not true. Option D is also incorrect because it simply restates the abbreviation without providing any explanation of what TIA actually means.
A woman sees her primary care provider because of extreme fatigue for the past 2 months; she difficulty lifting even light objects. Her physician suspects myasthenia gravis. Which of the ff. tests should the nurse anticipate to confirm this diagnosis?
- A. Mestinon test
- B. Pulmonary function studies
- C. Quinine tolerance test
- D. Tensilon test
Correct Answer: D
Rationale: The correct answer is D: Tensilon test. The Tensilon test involves administering edrophonium (Tensilon) to temporarily improve muscle weakness in myasthenia gravis patients, confirming the diagnosis. Other choices are incorrect: A (Mestinon test) is not a standard diagnostic test for myasthenia gravis, B (Pulmonary function studies) are not specific for myasthenia gravis, and C (Quinine tolerance test) is not a relevant test for this condition.