Nokea
The nurse working in the PACU is aware that which of the following procedures may contribute to extracellular losses?
- A. Removal of an ingrown toenail
- B. Tooth extraction
- C. Abdominal surgery
- D. Cataract surgery
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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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.
A nurse preparing to start an IV on a newly admitted patient teaches the patient about the procedure and begins to prepare the site. The nurse should always start by:
- A. Leaving one hand ungloved to assess the site
- B. Preparing the skin with an iodine solution
- C. Asking the patient if he is allergic to latex or iodine
- D. Removing excessive hair at the selected site
Correct Answer: C
Rationale: Before preparing the skin, the nurse should ask the patient if he or she is allergic to latex or iodine, which are products commonly used in setting up for IV therapy. A local reaction could result in irritation to the IV site or, in the extreme, it could result in anaphylaxis, which can be life threatening.
A patient is taking spironolactone (Aldactone) to control her hypertension. Her serum potassium level is 6 mEq/L. For this patient, the nurse's priority would be to assess her:
- A. Neuromuscular function
- B. Bowel sounds
- C. Respiratory rate
- D. Electrocardiogram (ECG) results
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The patient asks the nurse if he will die if air bubbles get into the IV tubing. What is the nurse's best response?
- A. The system is closed and that is impossible.
- B. Only relatively large volumes of air administered rapidly are dangerous.
- C. There is a risk of complication with IV administration.
- D. You watch too many movies.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The renin and angiotensin systems help to maintain the balance of sodium and water in the body. What other functions do these systems serve?
- A. Regulating hemoglobin levels
- B. Maintaining a healthy blood volume
- C. Releasing platelets when tissues are injured
- D. Lowering blood volumes
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.