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One of the dangers of treating hypernatremia is:
- A. Red blood cell crenation
- B. Cerebral edema
- C. Red blood cell hydrolysis
- D. Renal shutdown
Correct Answer: B
Rationale: The correct answer is B: Cerebral edema. Hypernatremia is an elevated sodium level in the blood, which can lead to osmotic shifts causing water to move out of cells, including brain cells. This can result in cerebral edema, potentially leading to neurological complications.
Incorrect choices:
A: Red blood cell crenation - This occurs in hypertonic solutions, not hypernatremia.
C: Red blood cell hydrolysis - Hypernatremia doesn't directly cause red blood cell hydrolysis.
D: Renal shutdown - Hypernatremia can stress the kidneys, but it doesn't typically lead to renal shutdown.
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Which laboratory study is monitored for the patient receiving heparin therapy?
- A. INR
- B. PTT
- C. PT
- D. Bleeding time
Correct Answer: B
Rationale: The correct answer is B: PTT (Partial Thromboplastin Time) because it specifically measures the effectiveness of heparin therapy by assessing the intrinsic pathway of the coagulation cascade. A prolonged PTT indicates that heparin is achieving the desired anticoagulant effect.
A: INR (International Normalized Ratio) is used to monitor warfarin therapy, not heparin.
C: PT (Prothrombin Time) is also used to monitor warfarin therapy.
D: Bleeding time is not typically used to monitor heparin therapy and is more focused on platelet function rather than coagulation factors.
The nurse is evaluating whether a patient’s turning schedule was effective in preventing the formation of pressure ulcers. Which finding indicates success of the turning schedule?
- A. Staff documentation of turning the patient every 2 hours
- B. Presence of redness only on the heels of the patient
- C. Patient’s eating 100% of all meals NursingStoreRN
- D. Absence of skin breakdown
Correct Answer: D
Rationale: The correct answer is D because the absence of skin breakdown indicates that the turning schedule was effective in preventing pressure ulcers. Skin breakdown is a key indicator of pressure ulcer development, so its absence suggests that the patient's skin integrity was maintained. Choice A is incorrect because documentation alone does not guarantee successful prevention. Choice B is incorrect as redness on the heels can still indicate the early stages of pressure ulcers. Choice C is unrelated to skin integrity and pressure ulcer prevention.
. A client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. The nurse explains that these medications are only effective if the client:
- A. prefers to take insulin orally.
- B. has type 1diabetes.
- C. has type 2 diabetes.
- D. is pregnant and has type 2 diabet
Correct Answer: B
Rationale: Rationale:
1. Oral antidiabetic agents target insulin resistance, common in type 2 diabetes.
2. Type 1 diabetes lacks insulin production, making oral agents ineffective.
3. Choice A is incorrect as insulin cannot be taken orally.
4. Choice C is incorrect as oral agents are not indicated for type 2 diabetes.
5. Choice D is incorrect as pregnancy does not affect the type of diabetes.
A nurse is conducting a nursing health history. Which component will the nurse address?
- A. Nurse’s concerns
- B. Patient expectations
- C. Current treatment orders
- D. Nurse’s goals for the patient
Correct Answer: B
Rationale: The correct answer is B: Patient expectations. During a nursing health history, it is essential for the nurse to address the patient's expectations to understand their needs, preferences, and goals for care. By focusing on the patient's expectations, the nurse can provide patient-centered care and tailor interventions to meet the patient's specific needs.
A: Nurse's concerns - While it is important for the nurse to consider their own concerns, the primary focus should be on the patient's needs and expectations.
C: Current treatment orders - This is important information to gather, but it does not directly address the patient's expectations or preferences.
D: Nurse's goals for the patient - The nurse should work collaboratively with the patient to establish goals that align with the patient's expectations and preferences, rather than imposing their own goals.
A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo- oopherectomy with tumor secretion, omentectomy, appendectomy, and lymphadenopathy. During the second postoperative day, which of the following assessment findings would raise concern in the nurse?
- A. Abdominal pain
- B. Serous drainage from the incision
- C. Hypoactive bowel sounds
- D. Shallow breathing and increasing lethargy
Correct Answer: D
Rationale: The correct answer is D: Shallow breathing and increasing lethargy. This finding could indicate a potential respiratory complication such as atelectasis or pneumonia, which are common postoperative complications. Shallow breathing can lead to inadequate oxygenation and ventilation, causing lethargy due to decreased oxygen delivery to tissues. It is crucial to assess and address respiratory issues promptly to prevent further complications.
A: Abdominal pain is expected postoperatively and can be managed with pain medications.
B: Serous drainage from the incision is a normal finding after surgery and indicates the wound is healing properly.
C: Hypoactive bowel sounds are common after surgery due to decreased peristalsis and can be managed with interventions such as early ambulation and medications.