Nokea
The nurse caring for a client in shock recognizes that the glomerular filtration rate of the kidneys will fail if the client's mean arterial pressure falls below which of the following levels?
- A. 140
- B. 120
- C. 100
- D. 80
Correct Answer: D
Rationale: A mean arterial pressure (MAP) below 80 mmHg compromises renal perfusion, leading to glomerular filtration failure. Higher MAPs (A, B, C) maintain adequate kidney function.
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Clients receiving antipsychotic drug therapy will often exhibit extrapyramidal side effects that are reversible with which of the following agents ordered by the physician?
- A. Phenothiazines
- B. Anticholinergics
- C. Anti-Parkinsonian drugs
- D. Tricyclic agents
Correct Answer: B
Rationale: This answer is incorrect. Phenothiazines are antipsychotic drugs and produce the symptoms. This answer is correct. Anticholinergic agents are often used prophylactically for extrapyramidal symptoms. They balance cholinergic activity in the basal ganglia of the brain. This answer is incorrect. Anti-Parkinsonian drugs would increase the symptoms. This answer is incorrect. Tricyclic agents are used for symptoms of depression.
A first-trimester primigravida is diagnosed with anemia. The nurse should suspect that this anemia is a result of:
- A. Mother's increased blood volume
- B. Mother's decreased blood volume
- C. Fetal blood volume increase
- D. Increase in iron absorption
Correct Answer: A
Rationale: Increased maternal blood volume in the first trimester causes dilutional anemia due to a relative decrease in red blood cell concentration.
Which guidelines would hamper staff learning and compliance?
- A. Provide scientific information regarding nosocomial infections.
- B. Clarify information with staff during each session.
- C. Acknowledge resistance of staff to changes in policies.
- D. Utilize diagrams to provide information.
- E. Provide all information needed to the staff on the first session.
- F. Tell the staff that changes were mandated by hospital policy.
- G. Send a memo regarding errors in IV site care procedure.
Correct Answer: E, F, G
Rationale: Providing all information in one session (E) can overwhelm staff, reducing retention. Stating changes are mandated (F) may foster resentment, decreasing compliance. Sending a memo about errors (G) may seem punitive, discouraging engagement. In contrast, scientific information (A), clarification (B), acknowledging resistance (C), and diagrams (D) promote understanding and acceptance.
The surgical nurse is preparing a patient for surgery on the lower abdomen. In which position would the nurse most likely place the client for surgery on this area?
- A. Lithotomy
- B. Sim's
- C. Prone
- D. Trendelenburg
Correct Answer: A
Rationale: The lithotomy position is used for lower abdominal surgeries (e.g., gynecologic procedures) to provide access to the pelvic area. Sim's (B) is for rectal exams, prone (C) for back surgeries, and Trendelenburg (D) for shock or upper abdominal access.
The client is admitted with a diagnosis of hypovolemic shock. Which fluid is most appropriate for initial resuscitation?
- A. 0.9% Normal saline
- B. 5% Dextrose in water
- C. 3% Sodium chloride
- D. Lactated Ringer’s
Correct Answer: A
Rationale: 0.9% Normal saline is the preferred isotonic fluid for initial resuscitation in hypovolemic shock to restore intravascular volume. Dextrose is hypotonic, 3% saline is hypertonic, and lactated Ringer’s is used in specific cases like burns.