Nokea
The major electrolytes in the extracellular fluid are:
- A. potassium and chloride
- B. potassium and phosphate
- C. sodium and chloride
- D. sodium and phosphate
Correct Answer: C
Rationale: The correct answer is C: sodium and chloride. In the extracellular fluid, sodium and chloride are the major electrolytes due to their roles in maintaining fluid balance, nerve function, and muscle contraction. Potassium and phosphate (choice B) are primarily found in intracellular fluid, while potassium and chloride (choice A) are not the major electrolytes in extracellular fluid. Similarly, sodium and phosphate (choice D) are not major extracellular electrolytes. Thus, choice C is the correct answer based on the significant presence and functions of sodium and chloride in the extracellular fluid.
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What assessment framework provides additional modesty for clients, such as teenage girls?
- A. Body systems
- B. Functional
- C. Focused
- D. Head to toe
Correct Answer: D
Rationale: The correct answer is D: Head to toe. This assessment framework allows for modesty by assessing one body part at a time, starting from the head down to the toe. This approach ensures clients, especially teenage girls, feel comfortable and respected during the assessment process. Other choices like A (Body systems) involve assessing multiple body parts simultaneously, potentially compromising modesty. Functional assessment (B) focuses on assessing specific functions rather than individual body parts, which may not address the modesty concern. Focused assessment (C) targets a specific area of concern, which may not provide a comprehensive evaluation while also potentially overlooking modesty concerns.
A nurse is assessing a patient who is experiencing dizziness and weakness. The nurse should prioritize which of the following?
- A. Blood pressure measurement.
- B. Pulse oximetry.
- C. Blood glucose levels.
- D. Cardiac monitoring.
Correct Answer: A
Rationale: The correct answer is A: Blood pressure measurement. Dizziness and weakness can be symptoms of hypotension or low blood pressure. Prioritizing blood pressure measurement is crucial because it can indicate if the patient is at risk of complications like cardiovascular collapse. Pulse oximetry (B) is important for assessing oxygen levels in the blood but may not directly address dizziness and weakness. Blood glucose levels (C) are important but not the priority in this scenario. Cardiac monitoring (D) may be necessary but should come after assessing blood pressure to rule out immediate life-threatening conditions.
What is the most appropriate action when a client with suspected meningitis presents with a positive Brudzinski sign?
- A. Place the client on their back and administer pain medication
- B. Place the client on their side and administer antibiotics
- C. Administer IV fluids and antibiotics
- D. Perform a lumbar puncture
Correct Answer: D
Rationale: The correct answer is D, perform a lumbar puncture. A positive Brudzinski sign indicates meningeal irritation, a hallmark of meningitis. A lumbar puncture is the gold standard for diagnosing meningitis by analyzing cerebrospinal fluid. Placing the client on their back without proper diagnosis or treatment delays could lead to serious complications. Option B is incorrect as antibiotics should be given after confirming the diagnosis. Option C is partially correct but does not address the need for a definitive diagnostic test. Option A is incorrect as pain medication alone does not address the underlying cause of meningitis.
Which technique should the nurse use to determine the presence of crepitus during a physical examination?
- A. Percussion
- B. Auscultation
- C. Palpation
- D. Auscultation
Correct Answer: A
Rationale: The correct technique to determine the presence of crepitus during a physical examination is palpation. Crepitus is a crackling or grating sensation that is felt when there is air trapped in the subcutaneous tissue. Palpation involves using the hands to feel for abnormalities such as crepitus. Percussion involves tapping on the body to produce sounds that can help assess underlying structures, not to determine the presence of crepitus. Auscultation is listening to sounds within the body using a stethoscope, which is not relevant for detecting crepitus.
What should a nurse assess for in a client with an arteriovenous fistula for hemodialysis?
- A. Inspect for visible pulsation
- B. Palpate for thrill
- C. Auscultate for bruit
- D. Percuss for dullness
Correct Answer: A
Rationale: The correct answer is A: Inspect for visible pulsation. This is because an arteriovenous fistula for hemodialysis should have a visible pulsation, indicating proper blood flow. Palpating for thrill (B) and auscultating for bruit (C) are also common assessments for an arteriovenous fistula, but inspecting for visible pulsation is the most direct and reliable way to assess the patency of the fistula. Percussing for dullness (D) is not relevant in this context as it does not provide information about the vascular access site.