Nokea
Nursing interventions for a patient with a diagnosis of hyponatremia includes all of the following except:
- A. Assessing for symptoms of nausea and malaise
- B. Encouraging the intake of low-sodium liquids, such as coffee or tea
- C. Monitoring neurological status
- D. Restricting tap water intake
Correct Answer: B
Rationale: Hyponatremia is a condition characterized by low levels of sodium in the blood. Encouraging the intake of low-sodium liquids, such as coffee or tea, can further dilute the sodium levels in the body and worsen the condition. Instead, it is important to restrict fluid intake and focus on providing appropriate electrolyte replacement. Monitoring the patient's neurological status is crucial as severe hyponatremia can lead to neurological symptoms such as confusion, seizures, and coma. Assessing for symptoms like nausea and malaise helps in understanding the patient's condition. Restricting tap water intake is also necessary to help manage hyponatremia by preventing further dilution of sodium levels.
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Which is an important nursing consideration when suctioning a young child who has had heart surgery?
- A. Perform suctioning at least every hour.
- B. Suction for no longer than 30 seconds at a time.
- C. Administer supplemental oxygen before and after suctioning.
- D. Expect symptoms of respiratory distress when suctioning.
Correct Answer: B
Rationale: Suctioning for no longer than 30 seconds at a time is an important nursing consideration when suctioning a young child who has had heart surgery. Prolonged suctioning can cause hypoxemia and decrease the child's oxygen saturation, which can be detrimental, especially in postoperative patients who may have compromised cardiopulmonary reserves. It is crucial to minimize the duration of suctioning to prevent potential complications. Additionally, hyperoxygenation before and after suctioning may help maintain adequate oxygen levels and minimize the risk of hypoxemia in these vulnerable patients.
If a Wall unit is used, What should be the suctioning pressure required by James?
- A. 50-95 mmHg
- B. 100-120 mmHg
- C. 95-110 mmHg
- D. 155-175 mmHg
Correct Answer: A
Rationale: The recommended suction pressure range for suctioning an adult patient using a wall unit is typically between 80-120 mmHg. However, for a pediatric patient, the recommended suction pressure range is lower, usually between 50-95 mmHg. In this case, James' age is specified, so it is crucial to consider the appropriate suction pressure range for pediatric patients. Therefore, the suctioning pressure required by James should be in the range of 50-95 mmHg, making option A the correct answer.
The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
- A. Central venous pressure (CVP)
- B. Pulmonary artery capillary pressure (PACP)
- C. Pulmonary artery obstructive pressure (PACP)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The multilumen pulmonary artery catheter, when positioned in the small branches of the pulmonary artery, allows the nurse to measure various hemodynamic pressures. Central venous pressure (CVP), Pulmonary artery capillary pressure (PACP), and Pulmonary artery wedge pressure (PAWP) can be measured accurately at this point. However, "Pulmonary artery obstructive pressure" is not a valid or recognized hemodynamic pressure parameter. Instead, the correct term for this measurement that can be assessed using the catheter is the Pulmonary artery occlusion pressure (PAOP) or Pulmonary artery wedge pressure (PAWP), which reflects the left atrial pressure.
Which of the ff dietary recommendations should a nurse give to a client taking diuretics?
- A. Include potassium rich foods
- B. Avoid fruit and fruit juices
- C. Include protein rich foods
- D. Avoid dairy products
Correct Answer: A
Rationale: Diuretics are medications that help the body get rid of excess sodium and water through increased urine output. One common side effect of diuretics is the loss of potassium from the body. Therefore, it is important for clients taking diuretics to include potassium-rich foods in their diet to help maintain a healthy potassium level. Some examples of potassium-rich foods include bananas, oranges, potatoes, spinach, avocados, and tomatoes. By including these foods in their diet, clients taking diuretics can help prevent potassium deficiency and maintain overall health.
Which may be given to high-risk children after exposure to chickenpox to prevent varicella?
- A. Acyclovir (Zovirax)
- B. Varicella globulin
- C. Diphenhydramine hydrochloride (Benadryl)
- D. VCZ immune globulin (VariZIG)
Correct Answer: D
Rationale: VCZ immune globulin (VariZIG) is given to high-risk children after exposure to chickenpox to prevent varicella. VariZIG contains antibodies against the varicella-zoster virus, providing passive immunity to the child. This can help reduce the severity of the infection or prevent it altogether in high-risk individuals. Acyclovir (Zovirax) is an antiviral medication used to treat varicella infections but is not typically used for prevention post-exposure. Varicella globulin is not a treatment for varicella. Diphenhydramine hydrochloride (Benadryl) is an antihistamine and is not used for preventing varicella post-exposure.