Nokea
The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:
- A. Provide nutrients
- B. Increase protein stores
- C. Elevate the circulating blood volume
- D. Divert blood flow away from the liver temporarily
Correct Answer: C
Rationale: The correct answer is C: Elevate the circulating blood volume. Albumin increases the circulating blood volume, which helps to reduce ascites and improve hemodynamics in clients with portal hypertension. Choice A is incorrect because salt-poor albumin is not primarily administered to provide nutrients. Choice B is incorrect because the main purpose of administering albumin is not to increase protein stores but to address fluid shifts. Choice D is incorrect because administering albumin does not divert blood flow away from the liver temporarily; instead, it helps improve blood volume and circulation.
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What is established when threats to air resources prevent evacuation by air from forward units?
- A. Area support medical battalions
- B. TOE units
- C. Ambulance exchange points
- D. Field hospitals
Correct Answer: C
Rationale: Ambulance exchange points are established when threats to air resources prevent evacuation by air from forward units. These points serve as locations where patients can be transferred between ground and air ambulances. Area support medical battalions (Choice A) refer to medical units that provide medical support to large areas and are not specifically related to evacuation. TOE units (Choice B) and field hospitals (Choice D) are not typically established in response to threats to air resources affecting evacuation.
A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent?
- A. Obtain a court order for the surgery
- B. Sign the informed consent on behalf of the client
- C. Send the client to surgery without the consent form being signed
- D. Obtain a telephone consent from a family member, with the consent being witnessed by two healthcare providers
Correct Answer: D
Rationale: In situations where a client is unable to sign the consent form, obtaining a telephone consent from a family member witnessed by two healthcare providers is the appropriate action to ensure informed consent is obtained. Option A is not necessary and involves legal proceedings. Option B is not ethical as the nurse cannot sign the consent on behalf of the client. Option C is unsafe and violates the client's rights by proceeding without proper consent.
The nurse prepares to administer digoxin (Lanoxin) to a newborn with a diagnosis of heart failure and notes that the apical rate is 140 beats per minute. Which nursing action is appropriate?
- A. Hold the medication
- B. Administer the digoxin
- C. Notify the healthcare provider
- D. Recheck the apical rate in 1 hour
Correct Answer: B
Rationale: An apical rate of 140 bpm is within the normal range for a newborn. Digoxin is commonly used to treat heart failure by increasing the strength and efficiency of the heart's contractions. Since the heart rate is within the normal range, there is no need to hold the medication or notify the healthcare provider. Rechecking the apical rate in an hour is unnecessary as the heart rate is not alarming. Therefore, the appropriate nursing action is to administer the digoxin.
A client is prescribed lisinopril (Zestril) for the treatment of hypertension. He asks the nurse about possible adverse effects. The nurse should inform him about which common adverse effects of angiotensin-converting enzyme (ACE) inhibitors?
- A. Constipation
- B. Dizziness
- C. Headache
- D. B, C
Correct Answer: D
Rationale: The correct answer is D: 'Dizziness' and 'Headache'. ACE inhibitors like lisinopril are known to cause these common side effects due to their blood pressure-lowering effects. Choice A, 'Constipation', is not a common adverse effect associated with ACE inhibitors. While constipation can be a side effect of some medications, it is not typically seen with ACE inhibitors. Therefore, options A and B are incorrect choices.
Patients with gallbladder disease should reduce their intake of:
- A. Protein
- B. Sodium
- C. Cholesterol
- D. Fat
Correct Answer: D
Rationale: Patients with gallbladder disease should reduce their intake of fat because high-fat foods can trigger gallbladder symptoms such as pain and indigestion. While proteins, sodium, and cholesterol may also need to be moderated for overall health, reducing fat intake is particularly crucial for managing gallbladder issues.