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The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient’s urine output has been less than 20 mL/hour for the past 2 hours. The patient’s blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should

  • A. contact the provider and expect a prescription for a normal saline bolus.
  • B. wait until the provider makes rounds to report the assessment findings.
  • C. continue to evaluate urine output for 2 more hours.
  • D. ignore the urine output, as this is most likely postrenal in origin.
Correct Answer: A

Rationale: Rationale:
1. Urine output < 20 mL/hour indicates potential hypoperfusion.
2. Decreased urine output with hypotension and tachycardia suggests inadequate fluid resuscitation.
3. Administering a normal saline bolus can help improve perfusion and stabilize blood pressure.
4. Contacting the provider promptly for orders is crucial in managing this acute situation.

Summary of Incorrect Choices:
B. Delaying reporting to the provider risks worsening the patient's condition.
C. Continuing to evaluate urine output without intervention can lead to further deterioration.
D. Ignoring the urine output due to potential postrenal causes overlooks the urgent need for fluid resuscitation.

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The nurse is caring for a patient receiving peritoneal dialysis. The patient suddenly complains of abdominal pain and chills. The patient’s temperature is elevated. The nurse should

  • A. assess peritoneal dialysate return.
  • B. check the patient’s blood sugar.
  • C. evaluate the patient’s neurological status.
  • D. inform the provider of probable visceral perforation.
Correct Answer: D

Rationale: The correct answer is D: inform the provider of probable visceral perforation. This is the most urgent action as sudden abdominal pain, chills, and elevated temperature in a patient receiving peritoneal dialysis could indicate a serious complication like visceral perforation, which requires immediate medical attention to prevent further complications. Assessing peritoneal dialysate return (A) may provide some information but does not address the urgent need to address a potential visceral perforation. Checking the patient's blood sugar (B) and evaluating the patient's neurological status (C) are not priorities in this situation and do not address the potential life-threatening complication of visceral perforation.

The nurse is providing insulin education for an elderly patient with long-standing
diabetes. A prescription has been written for the patient to take 20 units of insulin glargine at 10
PM nightly. The nurse should instruct the patient that the peak of the insulin action for this agent
is

  • A. 200
  • B. 400
  • C. 800
  • D. peakless
Correct Answer: D

Rationale: The correct answer is D: peakless. Insulin glargine is a long-acting insulin with a smooth, consistent release of insulin over 24 hours, providing a steady level of insulin without a pronounced peak. This characteristic helps in maintaining stable blood glucose levels. Options A, B, and C are incorrect as they refer to peak values that do not apply to insulin glargine.

The most common reasons for initiating dialysis in acute kidney injury include which of the following? (Select all that apply.)

  • A. Acidosis
  • B. Hypokalemia
  • C. Volume overload
  • D. Hyperkalemia
Correct Answer: A

Rationale: Explanation:
A: Acidosis is a common reason to initiate dialysis in acute kidney injury due to impaired acid-base balance.
B: Hypokalemia is not a common reason for initiating dialysis in acute kidney injury.
C: Volume overload may require dialysis but is not as common as acidosis.
D: Hyperkalemia is a valid reason for dialysis but not as common as acidosis in acute kidney injury.

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 a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition?

  • A. Daily weight
  • B. Fingerstick glucose
  • C. Lung sound auscultation
  • D. Urine osmolality
Correct Answer: D

Rationale: The correct answer is D: Urine osmolality. In head trauma patients, the risk of developing diabetes insipidus (DI) is high due to damage to the posterior pituitary. Monitoring urine osmolality helps identify DI early, as low urine osmolality indicates impaired concentration ability. This is crucial for prompt treatment to prevent dehydration. Choices A and B are important but not specific to endocrine disorders. Choice C is relevant for respiratory assessment, not endocrine disorders.

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