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The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.)
- A. Acidosis
- B. Hypokalemia
- C. Volume overload
- D. Hyperkalemia
Correct Answer: C
Rationale: The correct answer is C: Volume overload. In acute kidney injury, impaired kidney function leads to fluid retention, causing volume overload. Dialysis helps remove excess fluid to restore fluid balance. Acidosis and hyperkalemia are potential complications of acute kidney injury but not the primary reasons for initiating dialysis. Hypokalemia is unlikely in acute kidney injury due to impaired excretion of potassium by the kidneys. Therefore, the most common reason for initiating dialysis in acute kidney injury is to manage volume overload.
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The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
- A. Use tweezers to remove any remaining ticks.
- B. Check the vital signs, including temperature.
- C. Give doxycycline (Vibramycin) 100 mg orally.
- D. Obtain information about recent outdoor activities.
Correct Answer: A
Rationale: The correct answer is A: Use tweezers to remove any remaining ticks. The first step is to remove the tick to prevent further transmission of any potential pathogens. This is crucial in preventing tick-borne illnesses. Checking vital signs (B) can be done after the tick is removed. Administering doxycycline (C) should be based on guidelines and individual factors. Obtaining information about recent outdoor activities (D) is important but not the immediate priority.
The nurse manager is assisting a nurse with improving organizational skills and time management. Which nursing activity is the priority in pre-planning a schedule for selected nursing activities in the daily assignment?
- A. Tracheostomy tube suctioning.
- B. Medication administration.
- C. Colostomy care instruction.
- D. Client personal hygiene.
Correct Answer: B
Rationale: The correct answer is B: Medication administration. This is the priority because medication administration is time-sensitive and crucial for patient safety. It requires precise timing and cannot be delayed. Tracheostomy tube suctioning (A), colostomy care instruction (C), and client personal hygiene (D) are important nursing activities but can be adjusted within the schedule based on patient needs and acuity levels. Prioritizing medication administration ensures that patients receive their medications on time, preventing adverse events and promoting optimal health outcomes.
A patients family is exhibiting increasingly impaired coping as the patients condition deteriorates. The nurse asks the family to state the biggest concern from their perspective.What is the most important rationale for this question?
- A. The question indicates active listening on the part of the nurse.
- B. The question is used as a way to validate the familys knowledge.
- C. The question clarifies the nurses understanding of current family needs.
- D. The question promotes problem definition, which helps define the degree of family understanding.
Correct Answer: C
Rationale: The correct answer is C because asking the family to state their biggest concern clarifies the nurse's understanding of the current family needs. This step allows the nurse to assess the specific areas where the family may require support or assistance, leading to more tailored interventions. By identifying the primary concern, the nurse can better address the family's emotional, informational, or practical needs.
Choice A is incorrect because the question is not solely about active listening; it serves a deeper purpose of assessment. Choice B is incorrect as the question goes beyond validating knowledge to understanding emotional and practical needs. Choice D is incorrect because the question focuses on identifying concerns rather than defining the degree of understanding.
Many critically ill patients experience anxiety. The nurse can reduce anxiety with which approach?
- A. Asking family members to limit their visitation to 2-hour periods in morning, afternoon, and evening. You know that this is the best approach to ensure uninterrupted rest time for the patient. Tell the patient, “Your family is in the waiting room. They will be permitted to come in at 2:0 0 PM after you take a short nap.”
- B. Explaining the unit routine. “Assessments are done every 4 hours; patients are bathed on the night shift around 5:00 AM; family memabbierbr.sc oamr/ete spt ermitted to visit you after the physicians make their morning rounds. They can spend the day. Lights are out every night at 10:00 PM.”
- C. Stating, “It’s time to turn you. I am going to ask another nurse to come in and help me. We will turn you to your left side. During the turn , I’m going to inspect the skin on your back and rub some lotion on your back. T his should help to make you feel better.”
- D. Suctioning the endotracheal tube immediately when thaeb iprba.ctoiemn/tte sst tarts to cough. Sharing, “Your tube needs suctioned; you should feel better after I’m done.”
Correct Answer: C
Rationale: The correct answer is C because it addresses the patient's anxiety by providing clear communication and involving the patient in the care process. By explaining the turning procedure, inspecting the skin, and providing comfort through lotion application, the nurse establishes trust and promotes a sense of control for the patient. This approach helps alleviate anxiety by keeping the patient informed and engaged in their care.
Choice A is incorrect because limiting family visitation may not directly address the patient's anxiety. Choice B is incorrect as it focuses on routine information rather than directly addressing the patient's anxiety. Choice D is incorrect because suctioning the endotracheal tube may cause discomfort and does not address the underlying anxiety issue.
Which intervention is appropriate to assist the patient to co pe with admission to the critical care unit?
- A. Allowing unrestricted visiting by several family members at one time
- B. Explaining all procedures in easy-to-understand terms
- C. Providing back massage and mouth care
- D. Turning down the alarm volume on the cardiac monito r
Correct Answer: B
Rationale: The correct answer is B: Explaining all procedures in easy-to-understand terms. This intervention is appropriate as it helps reduce the patient's anxiety by providing clear information about what to expect during their stay in the critical care unit. This promotes a sense of control and understanding, which can positively impact the patient's coping mechanisms.
A: Allowing unrestricted visiting by several family members at one time may overwhelm the patient and interfere with their rest and recovery.
C: Providing back massage and mouth care may be beneficial but may not directly address the patient's need for information and understanding.
D: Turning down the alarm volume on the cardiac monitor may provide a more comfortable environment but does not address the patient's emotional and psychological needs related to coping with admission to the critical care unit.