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Ms. CC’s laboratory values indicate hemoconcentration secondary to fluid loss. Which of the following intravenous solutions would be most appropriate during initial fluid replacement therapy?
- A. 10% dextrose and saline
- B. 5% dextrose and water
- C. 5% dextrose and water with 60 mEq
- D. Distilled water KCl
Correct Answer: C
Rationale: The correct answer is C: 5% dextrose and water with 60 mEq. This solution is appropriate because it provides both fluid replacement (water) and electrolyte replacement (60 mEq). The dextrose helps prevent hypoglycemia. Choice A is incorrect as 10% dextrose and saline may worsen hemoconcentration. Choice B is not ideal as 5% dextrose and water lacks electrolytes needed for fluid balance. Choice D, distilled water with KCl, is dangerous as it lacks dextrose and may lead to electrolyte imbalances.
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An adult has a Hickman type central venous catheter and needs to have blood drawn from it. Which of the following should the nurse do first?
- A. Use sterile technique to assemble supplies needed
- B. Aspirate and discard the first 10 ml of the blood
- C. First flush the catheter with heparinized solution, then withdraw the blood
- D. Remove the cap of the catheter and replace it with a new one
Correct Answer: C
Rationale: The correct answer is C because flushing the central venous catheter with a heparinized solution before blood withdrawal is essential to maintain catheter patency and prevent clot formation. This step ensures the catheter is clear of any blockages, allowing for accurate blood sampling. Choice A is incorrect because assembling supplies should come after preparing the catheter. Choice B is incorrect as discarding blood before flushing the catheter may lead to inaccurate test results. Choice D is incorrect as replacing the catheter cap without flushing may lead to clot formation and catheter malfunction.
What is the mineral necessary for chemical clotting?
- A. Iron
- B. Potassium
- C. Sodium
- D. Calcium
Correct Answer: D
Rationale: The correct answer is D: Calcium. Calcium is necessary for the chemical clotting process because it plays a crucial role in the activation of various clotting factors, leading to the formation of a blood clot. Without sufficient calcium, the clotting cascade would not be able to proceed effectively. Iron (choice A) is essential for red blood cell production, not clotting. Potassium (choice B) and Sodium (choice C) are important for various physiological functions but are not directly involved in the clotting process.
Following a splenectomy, a client has a hemoglobin (Hb) level of 7.5g/dl and has vertigo when getting out of bed. The nurse suspects abnormal orthostatic changes. The vital sign values that would most support the nurse’s analysis are:
- A. Rise in blood pressure and heart rate
- B. Rise in blood pressure and drop in heart rate
- C. Drop in blood pressure and rise in heart rate
- D. none of the above
Correct Answer: C
Rationale: The correct answer is C: Drop in blood pressure and rise in heart rate. After a splenectomy, the client is at risk for orthostatic hypotension due to decreased blood volume. A drop in blood pressure and a compensatory rise in heart rate are common orthostatic changes. This occurs because the body tries to maintain perfusion to vital organs. A rise in blood pressure and heart rate (Choice A) would not align with orthostatic changes. A rise in blood pressure and drop in heart rate (Choice B) is contradictory to the body's compensatory response to maintain perfusion. Therefore, the most supportive vital sign values for abnormal orthostatic changes in this client would be a drop in blood pressure and a rise in heart rate.
A client has malignant lymphoma. As part of her chemotherapy, the physician prescribes chlorambucil (Leukeran), 10mg by mouth daily. When caring for the client, the nurse teaches her about adverse reactions to chlorambucil, such as alopecia. How soon after the first administration of chorambucil might this reaction occur?
- A. Immediately
- B. 2 to 3 weeks
- C. 1 week
- D. 1 month
Correct Answer: B
Rationale: The correct answer is B: 2 to 3 weeks. Alopecia (hair loss) is a common adverse reaction of chlorambucil, typically occurring 2 to 3 weeks after the first administration. This is due to the drug's effect on rapidly dividing cells, including hair follicles. Immediate onset (Choice A) is unlikely as it takes time for the drug to affect hair growth. One week (Choice C) is too soon for alopecia to manifest. One month (Choice D) is too long as alopecia usually occurs earlier. Therefore, the correct window for alopecia onset after chlorambucil administration is 2 to 3 weeks.
A patient visits her nurse practitioner (NP) after she has a cold for a week and is now experiencing a severe headache and fever. Her NP diagnoses a sinus infection. Which of the following additional symptoms is the patient likely to exhibit?
- A. Facial tenderness
- B. Photophobia
- C. Chest pain
- D. Ear drainage
Correct Answer: A
Rationale: The correct answer is A: Facial tenderness. Sinus infections commonly present with facial tenderness due to the inflammation and pressure within the sinuses. This symptom is often accompanied by pain or pressure around the eyes, cheeks, and forehead. Photophobia (B) is more commonly associated with conditions like migraines or meningitis. Chest pain (C) is not a typical symptom of a sinus infection. Ear drainage (D) is more indicative of an ear infection rather than a sinus infection.