Nokea
The nurse is caring for a patient who has had severe vomiting. The patient's serum sodium level is 130 mEq/L. The nurse will expect the patient's provider to order which treatment?
- A. Diuretic therapy
- B. Intravenous hypertonic 5% saline
- C. Intravenous normal saline 0.9%
- D. Oral sodium supplements
Correct Answer: C
Rationale: In this scenario, the patient has hyponatremia with a serum sodium level of 130 mEq/L. For a serum sodium level between 125 and 135 mEq/L, the appropriate treatment is intravenous normal saline 0.9%. Normal saline helps to increase the sodium content in the vascular fluid. Diuretic therapy would exacerbate sodium and fluid depletion, which is not suitable for a patient already dehydrated from severe vomiting. Intravenous hypertonic 5% saline is typically reserved for severe hyponatremia with a serum sodium level below 120 mEq/L. Oral sodium supplements are not feasible in this case as the patient is vomiting and may not be able to tolerate oral intake easily.
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The nurse is preparing to begin a medication regimen for a patient who will receive intravenous ampicillin and gentamicin. Which is an important nursing action?
- A. Administer each antibiotic to infuse over 15 to 20 minutes.
- B. Order serum peak and trough levels of ampicillin.
- C. Prepare the schedule so that the drugs are given at the same time.
- D. Set up separate tubing sets for each drug labeled with the drug name and date.
Correct Answer: D
Rationale: When administering intravenous aminoglycosides like gentamicin with penicillins such as ampicillin, it is crucial to avoid mixing them in the same container. Separate tubing sets labeled with the drug name and date should be used to prevent interactions between the medications. Administering each antibiotic over 15 to 20 minutes (Choice A) may not be appropriate for all medications and does not address the issue of compatibility. Ordering serum peak and trough levels of ampicillin (Choice B) is important for monitoring drug levels but does not directly address the administration process. Preparing a schedule to give drugs simultaneously (Choice C) may increase the risk of drug interactions and is not recommended when administering incompatible medications.
A client has the following arterial blood gas (ABG) results: pH 7.51, PCO2 31 mm Hg, PO2 94 mm Hg, HCO3 24 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: The ABG results show a pH above the normal range (7.35-7.45) and a decreased PCO2, indicating respiratory alkalosis. In respiratory alkalosis, the pH is increased and the PCO2 is decreased. Metabolic acidosis (choice A) would present with a low pH and low HCO3 levels. Metabolic alkalosis (choice B) would show an increased pH and HCO3 levels. Respiratory acidosis (choice C) would have a low pH and an increased PCO2.
A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.)
- A. You will not need vascular access to perform PD.
- B. There is less restriction of protein and fluids.
- C. You have flexible scheduling for the exchanges.
- D. All of the above
Correct Answer: D
Rationale: The correct answer is D, as all the statements are accurate advantages of peritoneal dialysis (PD). Peritoneal dialysis does not require vascular access, offers less restriction on protein and fluids, and provides flexibility in scheduling for the exchanges. Choice A is correct because one of the advantages of PD is not needing vascular access, which is required in hemodialysis. Choice B is correct because PD allows for less dietary restriction compared to hemodialysis. Choice C is correct because PD allows for flexible scheduling of exchanges, providing more independence to the individual undergoing treatment.
A nurse is teaching a nursing student how to measure a carotid pulse. The nurse should tell the student to measure the pulse on only one side of the client's neck primarily because:
- A. It is unnecessary to use both hands
- B. Feeling dual pulsations may lead to an incorrect measurement
- C. Palpating both carotid pulses simultaneously could occlude the trachea
- D. Palpating both carotid pulses simultaneously could cause the heart rate and blood pressure to drop
Correct Answer: D
Rationale: The correct answer is D. Applying pressure to both carotid arteries at the same time is contraindicated. Excess pressure to the baroreceptors in the carotid vessels could cause the heart rate and blood pressure to reflexively drop. Palpating both carotid pulses simultaneously could also interfere with the flow of blood to the brain, possibly causing dizziness and syncope. Choices A, B, and C are incorrect. It is necessary to use both hands to measure the carotid pulse accurately. Feeling dual pulsations does not lead to an incorrect measurement, and palpating both carotid pulses simultaneously does not occlude the trachea.
A nurse has a prescription to insert a nasogastric tube into the stomach of an assigned client. Which action should the nurse take to insert the tube safely and easily?
- A. Placing the tube in warm water
- B. Hyperextending the head while inserting the tube
- C. Removing the tube if any resistance to insertion is met
- D. Asking the client to swallow as the tube is being advanced
Correct Answer: D
Rationale: The correct action for the nurse to take to insert a nasogastric tube safely and easily is asking the client to swallow as the tube is being advanced. This action helps facilitate the passage of the tube through the esophagus into the stomach. Placing the tube in warm water (Choice A) is not a recommended practice for nasogastric tube insertion. Hyperextending the head (Choice B) can cause discomfort and is not necessary for safe insertion. Removing the tube if resistance is met (Choice C) is incorrect as it may cause harm or discomfort to the client. Asking the client to swallow helps the tube pass more smoothly and comfortably.