Nokea
The nurse is monitoring a patient in the postanesthesia care unit (PACU) for postoperative fluid and electrolyte imbalance. Which action will be most appropriate for the nurse to take?
- A. Encourage copious amounts of water.
- B. Start an additional intravenous (IV) line.
- C. Measure and record all intake and output.
- D. Weigh the patient and compare with preoperative weight.
Correct Answer: C
Rationale: The correct answer is C: Measure and record all intake and output. This action is most appropriate as it helps in assessing the patient's fluid status accurately. By tracking intake and output, the nurse can identify any imbalances and intervene promptly. Encouraging copious amounts of water (A) without monitoring intake and output can lead to fluid overload. Starting an additional IV line (B) may not be necessary if the current IV line is sufficient. Weighing the patient and comparing with preoperative weight (D) is important but may not provide real-time information on fluid and electrolyte balance. Monitoring intake and output is a comprehensive method to assess and manage fluid and electrolyte imbalances effectively.
You may also like to solve these questions
What is the function of the larynx?
- A. Enables speech
- B. Blocks food from entering the trachea
- C. Allows for passage of air and food
- D. Transfers air to the lungs
Correct Answer: A
Rationale: The correct answer is A: Enables speech. The larynx houses the vocal cords, which vibrate to produce sound during speech. The other choices are incorrect because B is the function of the epiglottis, which blocks food from entering the trachea, C is the function of the pharynx, which allows for the passage of air and food, and D is the function of the trachea, which transfers air to the lungs.
You are treating an adult trauma patient who was thrown from a moving vehicle. Upon assessment, you find the patient is hypotensive, has absent breath sounds on the right, and has visible tracheal deviation. What should you do first?
- A. Perform a needle decompression
- B. Administer a fluid bolus
- C. Intubate the patient
- D. Place the patient on a cardiac monitor
Correct Answer: A
Rationale: The correct answer is A: Perform a needle decompression. Tracheal deviation indicates tension pneumothorax, a life-threatening condition that requires immediate decompression. Performing a needle decompression will release the trapped air in the pleural space and relieve the pressure on the heart and lungs, stabilizing the patient's condition. Administering a fluid bolus (B) is not the priority as the hypotension is likely due to the tension pneumothorax. Intubating the patient (C) may worsen the condition by increasing the intrathoracic pressure. Placing the patient on a cardiac monitor (D) is important but not as urgent as addressing the tension pneumothorax.
A 15 year old male is brought to the ED after being involved in a motor vehicle crash. He is unconscious and was intubated at the scene by emergency personnel. Upon arrival at the ED, the patient's oxygen saturation is 92%, HR is 96 bpm and BP is 150/85. Breath sounds are decreased on the left side of the thorax. The next step is:
- A. Immediate needle cricothyroidotomy
- B. Reassess the position of the endotracheal tube
- C. Chest tube insertion
- D. Immediate needle thoracentesis
Correct Answer: B
Rationale: The correct answer is B: Reassess the position of the endotracheal tube. This is the next step because the patient has decreased breath sounds on the left side, indicating a potential issue with the endotracheal tube placement. Reassessing the position ensures proper oxygenation and ventilation. Immediate needle cricothyroidotomy (A) is not indicated as the patient is already intubated. Chest tube insertion (C) is not the immediate priority as the decreased breath sounds are likely due to endotracheal tube misplacement. Immediate needle thoracentesis (D) is not the correct step as there is no indication of a tension pneumothorax based on the patient's vital signs.
The nurse is completing a medication history for the surgical patient in preadmission testing. Which medication should the nurse instruct the patient to hold (discontinue) in preparation for surgery according to protocol?
- A. Warfarin
- B. Vitamin C
- C. Prednisone
- D. Acetaminophen
Correct Answer: A
Rationale: Step 1: Warfarin is an anticoagulant that increases the risk of bleeding during surgery.
Step 2: Holding Warfarin helps normalize the patient's clotting ability before surgery.
Step 3: This reduces the risk of excessive bleeding during and after the procedure.
Step 4: Vitamin C, Prednisone, and Acetaminophen do not pose the same bleeding risk.
Summary: Warfarin is the correct choice due to its anticoagulant properties, making it crucial to discontinue before surgery to minimize bleeding complications. Vitamin C, Prednisone, and Acetaminophen do not have the same impact on clotting and are safe to continue.
According to MyPlate a person should choose dairy products that contain
- A. 1% fat
- B. 2% fat
- C. 3% fat
- D. 4% fat
Correct Answer: A
Rationale: Step-by-step rationale:
1. MyPlate recommends choosing low-fat or fat-free dairy for better health.
2. 1% fat dairy is lower in saturated fat compared to 2%, 3%, or 4% fat options.
3. Lower fat content aligns with dietary guidelines for reducing saturated fat intake.
4. Choosing 1% fat dairy helps in maintaining a healthy weight and heart health.
Summary:
A is correct as it aligns with MyPlate's recommendation for low-fat dairy. B, C, and D are incorrect as they contain higher fat content, which may contribute to higher saturated fat intake and potential health risks.