Nokea
Place a washcloth between the skin and tourniquet
- A. Provide a bed bath instead of letting the client take a shower
- B. Use sterile technique when changing the dressing.
- C. Disconnect the intravenous fluid tubing prior to the clients bath.
- D. Use a plastic bag to cover the extremity with the device
Correct Answer: D
Rationale: The correct answer is D because using a plastic bag to cover the extremity with the device helps to keep the area dry when bathing, preventing the tourniquet from becoming wet and losing its effectiveness. This technique maintains the pressure needed for venipuncture.
A, providing a bed bath instead of a shower, is unrelated to the use of a tourniquet. B, using sterile technique for dressing changes, is important for wound care but not relevant to tourniquet use. C, disconnecting intravenous fluid tubing before a bath, is essential for preventing contamination but not directly related to tourniquet management.
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A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
- A. Ask family members to speak quietly to keep the client calm.
- B. Assess urine color, amount, and specific gravity each day.
- C. Encourage the client to drink at least 1 liter of fluids each shift.
- D. Dangle the client on the bedside before ambulating.
Correct Answer: D
Rationale: The correct answer is D because dangling the client on the bedside before ambulating helps prevent orthostatic hypotension and potential falls. This step allows the nurse to assess the client's tolerance to changes in position and reduces the risk of injury.
A: Asking family members to speak quietly does not directly address the prevention of injury related to dehydration.
B: Assessing urine parameters is important for monitoring hydration status but does not directly prevent injury.
C: Encouraging fluid intake is important for rehydration but does not directly address the risk of injury during ambulation.
The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a
diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?
- A. Cimetidine
- B. Maalox
- C. Potassium chloride elixir
- D. ) Furosemide
Correct Answer: A
Rationale: The correct answer is A: Cimetidine. In metabolic alkalosis, the blood pH is elevated due to excess bicarbonate. Cimetidine is a histamine-2 receptor antagonist that can help decrease gastric acid production, which can contribute to alkalosis. Maalox (B) is an antacid used to treat acid-related conditions, not alkalosis. Potassium chloride elixir (C) is used to correct potassium imbalances, not directly related to alkalosis. Furosemide (D) is a loop diuretic used to treat fluid retention and edema, not specifically indicated for metabolic alkalosis.
A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that do not apply.)
- A. Increased pulse rate
- B. . Distended neck veins
- C. Warm and pink skin
- D. Skeletal muscle weakness
Correct Answer: C
Rationale: Step 1: Fluid overload leads to increased fluid volume in the body, causing skin to appear pale, cool, and clammy due to poor circulation.
Step 2: "Warm and pink skin" is not a typical manifestation of fluid overload.
Step 3: Therefore, the correct answer is C.
Summary:
A: Increased pulse rate - Possible in fluid overload due to increased volume causing increased workload on the heart.
B: Distended neck veins - Common in fluid overload due to increased venous pressure.
C: Warm and pink skin - Incorrect, as skin is usually pale, cool, and clammy.
D: Skeletal muscle weakness - Not directly related to fluid overload.
. A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his
home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to
light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of
urine is present. What is the nurses most likely explanation for the low urine output?
- A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept
in place.
- B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
- C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in
decreased urine output. - D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that
results in diminished urine output.
Correct Answer: D
Rationale: The correct answer is D. The man's elevated heart rate, anxiety, and low urine output indicate a sympathetic reaction. This reaction stimulates the renin-angiotensin-aldosterone system, leading to decreased urine output. The sympathetic response triggers the release of renin, which activates angiotensin II and aldosterone, causing vasoconstriction and water reabsorption in the kidneys, ultimately reducing urine output. Choice A is incorrect because low urine output is not solely due to urinating before arrival. Choice B is incorrect as there is no indication of traumatic brain injury or ADH deficiency. Choice C is incorrect as atrial natriuretic peptide in heart failure typically increases urine output.
. A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an exam
- A. Increased rate and depth of respirations
- B. ncreased urinary output
- C. Increased thirst and hunger
- D. ncreased release of acids from the kidneys
Correct Answer: A
Rationale: The correct answer is A: Increased rate and depth of respirations. In this case, the client's arterial blood gas values show a pH within normal range (7.36), PaCO2 below normal (33 mm Hg), and HCO3 below normal (18 mEq/L), indicating a metabolic acidosis. To compensate for the acidosis, the client will hyperventilate, leading to increased rate and depth of respirations to blow off excess CO2 and attempt to normalize the pH. Options B, C, and D are incorrect because increased urinary output, thirst, hunger, and release of acids from the kidneys are not direct compensatory mechanisms for metabolic acidosis.