Nokea
Patient Josephine was referred to the physician, routine blood examinations were taken. After reviewing the serum electrolyte. levels an order of isotonic intravenous (IV) infusion was prescribed. Which IV solution should the nurse prepare?
- A. 5 percent dextrose in water
- B. 0.45 percent sodium chloride solution
- C. 10 percent dextrose in water
- D. 3 percent sodium chloride solution
Correct Answer: B
Rationale: The order for isotonic intravenous (IV) infusion indicates that the IV solution should have an osmolarity similar to that of blood serum, which is approximately 0.9 percent sodium chloride solution (normal saline). In the given choices, the closest option to isotonic solution is the 0.45 percent sodium chloride solution. This solution is hypotonic compared to blood serum, making it a suitable choice for isotonic IV infusion to prevent fluid shifts and maintain electrolyte balance in the patient. The other options, such as 5 percent dextrose in water (hypotonic), 10 percent dextrose in water (hypertonic), and 3 percent sodium chloride solution (hypertonic), do not match the requirement for an isotonic IV solution in this case.
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A patient with terminal cancer is experiencing severe pain despite receiving analgesics. Which intervention by the palliative nurse is most appropriate?
- A. Increase the dose of analgesics.
- B. Administer a different type of analgesic.
- C. Recommend non-pharmacological pain management techniques.
- D. Consult with a pain management specialist.
Correct Answer: D
Rationale: In a situation where a patient with terminal cancer is experiencing severe pain despite receiving analgesics, consulting with a pain management specialist is the most appropriate intervention. Pain management specialists have expertise in managing complex pain situations, especially in cases of terminal illness where pain control is crucial for improving quality of life. The specialist can review the current pain management plan, suggest alternative or adjunct therapies, adjust medication dosages, or explore different types of analgesics to optimize pain relief for the patient. Collaborating with a pain management specialist can help ensure the patient receives the most effective and personalized pain management approach tailored to their specific needs. Increasing the dose of analgesics, administering a different type of analgesic, or recommending non-pharmacological techniques may be appropriate interventions but should be guided by a specialist to ensure safe and effective pain management in a palliative care setting.
The labor progress and the physician performed amniotomy. Nurse Hope should FIRST assess tor _______.
- A. bladder distention
- B. maternal blood pressure
- C. cervical dilatation
- D. fetal heart rate (FHR) pattern
Correct Answer: D
Rationale: Following an amniotomy procedure during labor, Nurse Hope's priority should be to assess the fetal heart rate (FHR) pattern. This assessment is crucial to ensure the well-being and safety of the fetus. Changes in the FHR can provide valuable information about fetal distress or complications, allowing for timely interventions if needed. Monitoring the FHR pattern is a standard practice during labor and delivery to track the fetus's response to the changes in uterine activity. Therefore, assessing the FHR pattern should be the first priority after a labor progress and amniotomy.
Ms. C is at risk for refeeding syndrome that is caused by rapid feeding. What should be the priority action of the health care team to prevent complications associated with this syndrome?
- A. Assess for signs of pallor of the extremities and sluggish capillary refill
- B. Monitor for decreased bowel sounds, nausea, bloating, and abdominal distention
- C. Observe for signs of secret purging and ingestion of water to increase weight
- D. Monitor for peripheral edema, crackles in the lungs, and jugular vein distention
Correct Answer: B
Rationale: Refeeding syndrome is a potentially dangerous condition that can occur in malnourished individuals when nutrition is reintroduced too quickly. It is characterized by shifts in electrolytes, fluid imbalance, and metabolic abnormalities. Monitoring for decreased bowel sounds, nausea, bloating, and abdominal distention is the priority action to prevent complications associated with refeeding syndrome. These symptoms can indicate gastrointestinal issues such as ileus or overfeeding, which can lead to further complications. Early recognition and intervention can help prevent serious consequences of refeeding syndrome.
Which of the following screening tests is recommended for cervical cancer prevention in women aged 21 to 65 years?
- A. Human papillomavirus (HPV) testing alone
- B. Cytology (Pap smear) alone
- C. Co-testing with cytology and HPV testing
- D. Endometrial biopsy
Correct Answer: B
Rationale: The recommended screening test for cervical cancer prevention in women aged 21 to 65 years is cytology, also known as a Pap smear. The Pap smear is a test that looks for changes in the cells of the cervix that could indicate the presence of cervical cancer or pre-cancerous conditions. This test is recommended every 3 years for women aged 21-29 years, and every 3-5 years for women aged 30-65 years, depending on the screening method used. HPV testing alone or co-testing with both cytology and HPV testing may be used in certain situations, but for most women in this age group, cytology (Pap smear) alone is the recommended screening test.
The patient 's wife is-so anxious about the condition of her husband. The MOST appropriate INITIAL intervention for the nurse to make is to ________.
- A. describe her husband 's medical treatment since admission
- B. reassure her that the important fact is her presence
- C. explain the nature of the injury and reassure her that husband's condition is stable
- D. allow her to verbalize her feelings and concerns
Correct Answer: C
Rationale: In situations where a patient's family member is expressing anxiety about their loved one's condition, it is important for the nurse to provide clear and accurate information about the patient's status. By explaining the nature of the injury and reassuring the wife that her husband's condition is stable, the nurse can help alleviate her anxiety and address her concerns in a meaningful way. This intervention focuses on open communication and providing emotional support, which are crucial in helping the family member cope with the situation. It is essential to establish trust and create a supportive environment for the family member during this stressful time.