Nokea
The nurse is caring for a client who has experienced a thoracic spinal cord injury. In the event that spinal shock occurs, which intravenous (IV) fluid should the nurse anticipate being prescribed?
- A. Dextran
- B. 0.9% normal saline
- C. 5% dextrose in water
- D. 5% dextrose in 0.9% normal saline
Correct Answer: B
Rationale: Normal saline 0.9% is an isotonic solution that primarily remains in the intravascular space, increasing intravascular volume. This IV fluid would increase the client's blood pressure. Dextran is rarely used in spinal shock because isotonic fluid administration is usually sufficient. Additionally, Dextran has potential adverse effects. Dextrose 5% in water is a hypotonic solution that pulls fluid out of the intravascular space and is not indicated for shock. Dextrose 5% in normal saline 0.9% is hypertonic and may be indicated for shock resulting from hemorrhage or burns.
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A client who underwent peripheral arterial bypass surgery 16 hours ago reports that there is increasing pain in the leg that worsens with movement and is accompanied by paresthesias. Based on these data, which action should the nurse take?
- A. Call the primary health care provider.
- B. Administer an opioid analgesic.
- C. Apply warm moist heat for comfort.
- D. Apply ice to minimize any developing swelling.
Correct Answer: A
Rationale: Compartment syndrome is characterized by increased pressure within a muscle compartment caused by bleeding or excessive edema. It compresses the nerves in the area and can cause vascular compromise. The classic signs of compartment syndrome are pain at rest that intensifies with movement and the development of paresthesias. Compartment syndrome is an emergency, and the primary health care provider is notified immediately because the client could require an emergency fasciotomy to relieve the pressure and restore perfusion.
The nurse is creating a discharge plan for a postoperative client who had a unilateral adrenalectomy. What area of instruction should the nurse include in the plan to minimize the client's risk for injury?
- A. Teaching the client to maintain a diabetic diet
- B. Encouraging the adoption of a realistic exercise routine
- C. Providing a detailed list of the early signs of a wound infection
- D. Explaining the need for lifelong replacement of all adrenal hormones
Correct Answer: C
Rationale: A client who had a unilateral adrenalectomy (one adrenal gland was removed) will be placed on corticosteroids temporarily to avoid a cortisol deficiency; lifelong replacement is not necessary. Corticosteroids will be gradually weaned in the postoperative period until they are discontinued. Also, because of the anti-inflammatory properties of corticosteroids produced by the adrenals, clients who undergo an adrenalectomy are at increased risk of developing wound infections. Because of this increased risk of infection, it is important for the client to know measures to prevent infection, early signs of infection, and what to do if an infection seems to be present.
The nurse evaluates a client after treatment for carbon monoxide poisoning following a burn injury. The nurse should document that the treatment was effective if which finding was present? Select all that apply.
- A. The client is sleeping soundly.
- B. The client is awake and talking.
- C. Respiratory rate is 26 breaths/minute.
- D. The client's heart rate is 84 beats/minute.
- E. Carboxyhemoglobin levels are less than 5%.
- F. The heart monitor shows normal sinus rhythm.
Correct Answer: D,E,F
Rationale: Normal carboxyhemoglobin levels are less than 5% for a nonsmoking adult. Clients can be awake and talking with abnormally high levels. The symptoms of carbon monoxide poisoning are tachycardia, tachypnea, and central nervous system depression.
The nurse is developing a plan of care for an older client diagnosed with type 1 diabetes mellitus who is also experiencing acute gastroenteritis. To maintain food and fluid intake in order to prevent dehydration, which action should the nurse plan to include?
- A. Offering only water until the client is able to tolerate solid foods
- B. Withholding all fluids until vomiting has ceased entirely for at least 4 hours
- C. Encouraging the client to take 8 to 12 ounces of fluid every hour while awake
- D. Maintaining a clear liquid diet for at least 5 days before advancing to solid foods
Correct Answer: C
Rationale: Dehydration needs to be prevented in the client with type 1 diabetes mellitus because of the risk of diabetic ketoacidosis (DKA). Small amounts of fluid may be tolerated, even when vomiting is present. The client should be offered liquids containing both glucose and electrolytes. The diet should be advanced as tolerated and include a minimum of 100 to 150 g of carbohydrates daily.
The nurse reviews a primary health care provider's prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Headache is a common side effect of nitrates.
- B. Fever usually accompanies myocardial infarction.
- C. Acetaminophen potentiates the therapeutic effect of nitrates.
- D. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
Correct Answer: A
Rationale: Headache occurs as a side effect of nitrates in many clients. Acetaminophen may be administered before nitrates to prevent headaches or minimize the discomfort from the headaches.