Nokea
The nurse is aware that the shift of body fluids associated with the intravenous administration of albumin occurs by the process of:
- A. Filtration
- B. Osmosis
- C. Diffusion
- D. Active Transport
Correct Answer: A
Rationale: The correct answer is A: Filtration. Albumin is a large protein molecule that cannot pass through the semipermeable membrane of blood vessels. Therefore, the shift of body fluids associated with intravenous albumin administration occurs through the process of filtration, where fluid moves across the membrane due to a pressure difference. Osmosis (B) involves the movement of water across a semipermeable membrane, which is not the case for albumin. Diffusion (C) is the movement of molecules from an area of high concentration to low concentration, which is not how albumin moves. Active transport (D) requires energy to move substances against a concentration gradient, which is not the mechanism for albumin movement in the body.
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Which vein should be used first when initiating IV therapy?
- A. Jugular
- B. Basilic
- C. Brachiocephalic
- D. Axillary
Correct Answer: B
Rationale: The correct answer is B: Basilic vein. It is preferred for IV therapy due to its size, accessibility, and lower risk of complications. Basilic vein is deep and stable, aiding in successful catheter insertion and reduced risk of infiltration. Jugular vein (A) is not typically used due to the high risk of complications like infection. Brachiocephalic (C) and Axillary (D) veins are less commonly used as they are smaller and more prone to complications compared to the Basilic vein. In summary, the Basilic vein is the optimal choice for initiating IV therapy due to its size, accessibility, stability, and lower risk of complications.
Which drug class is used to reduce symptoms of muscle weakness from myasthenia gravis?
- A. Anticholinesterase drugs
- B. Adrenergic drugs
- C. Anticholinergic drugs
- D. Beta-blocker drugs
Correct Answer: A
Rationale: The correct answer is A: Anticholinesterase drugs. These drugs increase acetylcholine levels at neuromuscular junctions, helping improve muscle strength in myasthenia gravis. Adrenergic drugs (B) and beta-blocker drugs (D) are not typically used to treat muscle weakness in myasthenia gravis. Anticholinergic drugs (C) can worsen symptoms by blocking acetylcholine receptors, making them an inappropriate choice for this condition.
A nurse identifies a fall risk when assessing a patient upon admission. The nurse and the patient agree that the goal is for the patient to remain free from falls. However, the patient fell just before shift change. Which action is the nurse’s priority when evaluating the patient?
- A. Identify factors interfering with goal achievement.
- B. Counsel the nursing assistive personnel on duty when the patient fell. Remove the fall risk sign from the patient’s door because the patient has suffered a
- C. fall. Request that the more experienced charge nurse complete the documentation about
- D. the fall.
Correct Answer: A
Rationale: The correct answer is A: Identify factors interfering with goal achievement. This is the priority action because it focuses on understanding what caused the patient to fall despite the goal of preventing falls. By identifying the factors interfering with goal achievement, the nurse can make necessary adjustments to the care plan to prevent future falls.
Choice B is incorrect because counseling the nursing assistive personnel and removing the fall risk sign does not address the root cause of the fall.
Choice C is incorrect because shifting responsibility to the charge nurse for documentation does not address the immediate need to assess and address the factors contributing to the fall.
Choice D is incorrect because documenting the fall is important but not the priority when the immediate concern is understanding why the fall occurred.
What are the periods in life when the need for iron increases?
- A. Pregnancy
- B. Infancy
- C. Old age
- D. Male reproductive years
Correct Answer: A
Rationale: The correct answer is A: Pregnancy. During pregnancy, the need for iron increases significantly to support the growth of the fetus and to prevent maternal anemia. Iron is essential for the production of hemoglobin and for oxygen transport in the blood. In contrast, infants require iron for rapid growth and development, making choice B partially correct. Choice C (Old age) and choice D (Male reproductive years) are incorrect as the need for iron typically decreases in old age and remains relatively stable during male reproductive years.
Which of the following instructions should be included in the discharge teaching plan for a client after thyroidectomy for Grave’s disease?
- A. keep an accurate record of intake and output.
- B. use nasal desmopressin acetate (DDAVP).
- C. be sure to get regular follow-up care.
- D. Be sure to exercise to improve cardiovascular fitness.
Correct Answer: C
Rationale: Step 1: Patients with Grave's disease who undergo thyroidectomy require regular follow-up care for monitoring thyroid hormone levels and overall health.
Step 2: Regular follow-up care ensures early detection of any complications or recurrence of the disease.
Step 3: Monitoring helps in adjusting medication doses and managing any potential side effects.
Step 4: Choice A is important but not specific to thyroidectomy for Grave's disease. Choice B is not typically used post-thyroidectomy. Choice D may be beneficial but not a priority compared to regular follow-up care.