Nokea
The nurse who assesses the patient's peripheral IV site and notes edema around the insertion site will document which complication related to IV therapy?
- A. Air emboli
- B. Phlebitis
- C. Infiltration
- D. Fluid overload
Correct Answer: C
Rationale: Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate.
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A female patient is discharged from the hospital after having an episode of heart failure. She's prescribed daily oral doses of digoxin (Lanoxin) and furosemide (Lasix). Two days later, she tells her community health nurse that she feels weak and her heart "flutters" frequently. What action should the nurse take?
- A. Tell the patient to rest more often.
- B. Tell the patient to stop taking the digoxin, and call the physician.
- C. Call the physician, report the symptoms, and request to draw a blood sample to determine the patient's potassium level.
- D. Tell the patient to avoid foods that contain caffeine.
Correct Answer: C
Rationale: Furosemide is a potassium-wasting diuretic. A low potassium level may cause weakness and palpitations. Telling the patient to rest more often won't help the patient if she's hypokalemic. Digoxin isn't causing the patient's symptoms, so she doesn't need to stop taking it. The patient should probably avoid caffeine, but this wouldn't resolve potassium depletion.
A patient admitted with a gastrointestinal bleed and anemia is receiving a blood transfusion. Based upon the patient's hypotensive blood pressure, the nurse anticipates an order for IV fluids from the physician. Which of the following IV solutions may be administered with blood products?
- A. D5 and .45% Normal Saline
- B. Lactated Ringer's
- C. 5% dextrose in water
- D. 0.9% NaCl
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 73-year-old man who slipped on a small carpet in his home and fell on his hip is alert and oriented; PERRLA (pupils equally round and reactive to light and accommodation) is intact, and he has come by ambulance to the emergency department (ED). Heart rate elevated, he is anxious and thirsty. A Foley catheter is in place and 40mL of urine is present. The nurse's most likely explanation for the urine output is:
- A. The man urinated prior to his arrival in the ED and will probably not need to have the Foley catheter kept in place.
- B. The man has a brain injury, lacks ADH, and needs vasopressin.
- C. The man is in heart failure and is releasing atrial natriuretic peptide, which results in decreased urine output.
- D. He is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.
Correct Answer: D
Rationale: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely cause of the lower urine output.
Third spacing occurs when fluid moves out of the intravascular space but not into the intracellular space. Based upon this fluid shift, the nurse will expect the patient to demonstrate:
- A. Hypertension
- B. Bradycardia
- C. Hypervolemia
- D. Hypovolemia
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Your patient has alcoholism, and you may suspect during your assessment that his serum magnesium is low. What will the nurse potentially expect to assess related to hypomagnesemia?
- A. Tremor
- B. Pruritus
- C. Edema
- D. Decreased blood pressure
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.