Nokea
The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should
- A. apply a sterile gauze dressing to maintain sterility.
- B. replace the transparent dressing every 10 days to prevent manipulation.
- C. assess the catheter site for redness and/or swelling.
- D. use the catheter for drawing blood samples to reduce patient discomfort.
Correct Answer: C
Rationale: The correct answer is C because assessing the catheter site for redness and/or swelling is essential in monitoring for signs of infection or complications. Redness and swelling can indicate infection, which requires prompt intervention.
A: Applying a sterile gauze dressing is not necessary for a temporary percutaneous dialysis catheter unless specified by the healthcare provider.
B: Transparent dressings are typically left in place for several days unless there is a specific reason to change them more frequently.
D: Using the catheter for drawing blood samples is not recommended as it can increase the risk of infection and may interfere with the dialysis process.
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The patient has just returned from having an arteriovenous fistula placed. The patient asks, “When will they be able to use this and take this other catheter out?” The nurse should reply,
- A. “It can be used immediately, so the catheter can come out anytime.”
- B. “It will take 2 to 4 weeks to heal before it can be used.”
- C. “The fistula will be usable in about 4 to 6 weeks.”
- D. “The fistula was made using graft material, so it depends on the manufacturer.”
Correct Answer: C
Rationale: The correct answer is C: “The fistula will be usable in about 4 to 6 weeks.” This is because arteriovenous fistulas typically require a maturation period of 4 to 6 weeks before they can be used for dialysis. During this time, the fistula will develop into a strong, durable access point for hemodialysis.
Choice A is incorrect because the fistula needs time to mature before it can be used, and immediate use may damage it. Choice B is incorrect as it underestimates the maturation period required. Choice D is incorrect as the maturation time does not depend on the manufacturer but on the patient's physiology and healing process.
The most significant clinical finding of acute adrenal crisis associated with fluid and electrolyte imbalance is
- A. fluid volume excess.
- B. hyperglycemia.
- C. hyperkalemia
- D. hypernatremia
Correct Answer: C
Rationale: Step-by-step rationale for the correct answer (C: hyperkalemia):
1. Adrenal crisis leads to adrenal insufficiency, causing decreased cortisol levels.
2. Cortisol plays a crucial role in regulating potassium levels.
3. With decreased cortisol, potassium levels can rise, leading to hyperkalemia.
4. Hyperkalemia can result in life-threatening cardiac arrhythmias.
Summary:
A: Fluid volume excess is not typical in adrenal crisis.
B: Hyperglycemia can be present but is not the most significant finding.
D: Hypernatremia is not a typical feature of adrenal crisis.
Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.)
- A. Administer levothyroxine as prescribed.
- B. Encourage the intake of foods high in sodium.
- C. Initiate passive rewarming interventions.
- D. Monitor airway and respiratory effort.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Administering levothyroxine is crucial in treating myxedema coma as it helps replace the deficient thyroid hormone.
2. This intervention addresses the underlying cause of myxedema coma, which is severe hypothyroidism.
3. Levothyroxine administration can help reverse the symptoms of myxedema coma and improve the patient's condition.
Summary of Incorrect Choices:
- B: Encouraging high sodium intake is not appropriate as myxedema coma is associated with fluid retention and sodium may exacerbate this.
- C: Passive rewarming interventions are not relevant for myxedema coma, as the condition is not typically related to hypothermia.
- D: While monitoring airway and respiratory effort is important in general patient care, it is not a specific intervention for myxedema coma.
A 100-kg patient gets hemodialysis 3 days a week. In planning the care for this patient, the nurse recommends
- A. a diet of 2500 to 3500 kcal per day.
- B. protein intake of less than 50 grams per day.
- C. potassium intake of 10 mEq per day.
- D. fluid intake of less than 500 mL per day
Correct Answer: A
Rationale: The correct answer is A: a diet of 2500 to 3500 kcal per day. During hemodialysis, patients often experience increased energy expenditure due to the treatment process. Therefore, maintaining a higher caloric intake is crucial to prevent malnutrition and support the body's needs. Options B, C, and D are incorrect as limiting protein intake to less than 50 grams per day may lead to malnutrition in a patient undergoing hemodialysis, restricting potassium intake to 10 mEq per day may not be appropriate as individual needs vary, and restricting fluid intake to less than 500 mL per day can lead to dehydration and electrolyte imbalances in a patient undergoing hemodialysis.
The nurse is caring for an elderly patient who was admitted with renal insufficiency. An expected laboratory finding for this patient may be
- A. an increased glomerular filtration rate (GFR).
- B. a normal serum creatinine level.
- C. increased ability to excrete drugs.
- D. hypokalemia.
Correct Answer: C
Rationale: Correct Answer: C - Increased ability to excrete drugs.
Rationale:
1. Renal insufficiency impairs kidney function, leading to decreased excretion of drugs.
2. In elderly patients with renal insufficiency, there may be compensatory mechanisms to enhance drug excretion.
3. This increased ability to excrete drugs helps prevent drug accumulation and potential toxicity.
Summary:
A: Increased GFR is not expected in renal insufficiency; it typically decreases.
B: Serum creatinine level would likely be elevated in renal insufficiency, not normal.
D: Hypokalemia is not a typical lab finding in renal insufficiency; hyperkalemia is more common.