Nokea
The nurse is initiating an IV infusion of lactated Ringer's (LR) for the client in shock. What is the purpose of LR for this client?
- A. Increase fluid volume and urinary output
- B. Draw water from the cells into the blood vessels
- C. Provide dextrose and nutrients to prevent cellular death
- D. Replace potassium and magnesium for cardiac stabilization
Correct Answer: A
Rationale: A: LR is an isotonic crystalloid solution containing multiple electrolytes in approximately the same concentration as plasma. It enters the cells from the blood, provides fluids, and increases urinary output. B: A hypertonic solution draws fluid from the cells into the vascular compartment; LR is isotonic. C: LR alone does not contain dextrose. Formulations with dextrose are available. D: Magnesium is not a component of LR.
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The nurse is reviewing information for the 6-month-old who is being given ranitidine. Which finding should the nurse identify as an adverse effect of ranitidine?
- A. A heart rate of 110 bpm
- B. Oral temperature of 102.7°F (39.3°C)
- C. Spitting up some formula after each feeding
- D. A hard, pebble-like bowel movement every 2 days
Correct Answer: D
Rationale: A: An HR of 110 bpm is normal for a 6-month-old; the range is 80-170 bpm. B: Fever (temperature of 102.7°F) is not an adverse effect of ranitidine. C: Ranitidine is indicated for GERD; spitting up after feedings should improve. If not, then the medication dose may be too low or the medication itself ineffective. Spitting up is not a side effect. D: The nurse should identify that a hard, pebble-like bowel movement every 2 days demonstrates constipation; constipation is an adverse effect of ranitidine (Zantac).
The nurse receives the HCP order to start TPN for the client who has a PICC. Into which type of catheter illustrated should the nurse plan to administer the TPN?
- A. TPN_1.PNG
- B. TPN_2.PNG
- C. TPN_3.PNG
- D. TPN_4.PNG
Correct Answer: B
Rationale: A: Illustration A is a central line that is percutaneously inserted into the jugular or subclavian vein and terminates in the central circulation. These are intended for short-term venous access. B: Illustration B is a PICC, which is inserted into the arm and terminates in the central circulation. A PICC is used when medications or solutions are too caustic to be peripherally administered or when therapy lasts more than 2 weeks. C: Illustration C is a tunneled catheter inserted into the upper chest wall and threaded through the cephalic vein; it terminates in the central circulation. D: Illustration D is an intra-aortic balloon pump catheter that is inserted into the femoral artery and positioned in the descending aortic arch. The balloon on the end inflates during diastole. It is not used for medication or fluid administration.
A nurse working a surgical unit, notices a patient is experiencing SOB, calf pain, and warmth over the posterior calf. All of these may indicate which of the following medical conditions?
- A. Patient may have a DVT.
- B. Patient may be exhibiting signs of dermatitis.
- C. Patient may be in the late phases of CHF.
- D. Patient may be experiencing anxiety after surgery.
Correct Answer: A
Rationale: All of these factors (SOB, calf pain, and warmth) indicate a deep vein thrombosis (DVT), which can be a postoperative complication.
The 16-year-old, hospitalized for barbiturate overdose, is receiving low-dose dopamine at 1 mcg/kg/min. Which finding in the client's medical record illustrated should prompt the nurse to conclude that dopamine is effective?
- A. Decrease in PACs
- B. Increase in urine output
- C. Decrease in pulse pressure
- D. Increase in the diastolic BP
Correct Answer: B
Rationale: A: Dopamine (Intropin) will have no effect on decreasing the incidence of PACs. B: Low-dose dopamine, 0.5-2.0 mcg/kg/min, acts on dopaminergic receptor sites along afferent arterioles in the glomerulus, dilates the renal vasculature, and improves urine output. C: Positive inotropic effects of dopamine include an increase in systolic BP with an increase in pulse pressure. D: Positive inotropic effects of dopamine include an increase in systolic BP with little or no effect on DBP.
The client taking rifampin brings a sample of urine that is orange in color to the clinic. Which interventions should the nurse implement? Select all that apply.
- A. Send the urine to the lab for culture and sensitivity (C&S).
- B. Reassure the client that this is normal and harmless.
- C. Teach that the urine that is orange can stain clothing.
- D. Question continuation of rifampin with the HCP.
- E. Inform that sweat and tears can also turn orange-colored.
Correct Answer: B,C,E
Rationale: A: A C&S is unnecessary because orange-colored urine is a normal finding in the client taking rifampin. B: The nurse should reassure the client that orange-colored urine is a normal finding in the client taking rifampin (Rifadin). C: The nurse should teach the client that the orange-colored urine and sweat can stain clothing and that the client should consider wearing nonwhite clothing or using undergarments if sweating is excessive. D: It is unnecessary to question continuation of rifampin if the urine is orange-colored because this is a normal finding. E: The nurse should inform the client that other body fluids, such as tears, sweat, and saliva, can also turn orange-colored with the use of rifampin (Rifadin).