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 is assessing the patient for the presence of a Chvostek's sign. What electrolyte imbalance does a positive Chvostek's sign indicate?
- A. Hypermagnesemia
- B. Hypomagnesemia
- C. Hypocalcemia
- D. Hyperkalemia
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that 'she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.' The nurse explains to the woman that:
- A. She will need to have her medications adjusted and be readmitted to the hospital for a complete workup.
- B. Limiting fluids can create imbalances in the body that can result in confusion; maybe we need to adjust the timing of your fluids.
- C. It is normal to be a little confused following surgery and it is safe not to urinate at night.
- D. Confusion following surgery is common in the elderly due to loss of sleep.
Correct Answer: B
Rationale: The correct answer is B. In elderly patients, fluid deficits can lead to confusion and cognitive impairment. Limiting fluids can disrupt the body's balance, leading to such symptoms. Adjusting the timing of fluids can help maintain hydration without causing nighttime interruptions. Choices A, C, and D are incorrect because they do not address the underlying issue of fluid imbalance causing confusion. Choice A suggests unnecessary hospital readmission and medication adjustments. Choice C incorrectly normalizes confusion post-surgery and suggests it is safe not to urinate at night, which can exacerbate the issue. Choice D inaccurately attributes confusion to sleep loss rather than fluid imbalance.
A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?
- A. Place the patient in low Fowler's and notify the physician.
- B. Increase the patient's IV fluid and auscultate the lungs.
- C. Place the patient in semi-Fowler's and prepare to give the PRN diuretic as ordered.
- D. Discontinue the patient's IV.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse sees a variety of patients in the community health clinic. Which of the following patients would be at the greatest risk of dehydration?
- A. An 18-year-old basketball player with a stress fracture of the right foot
- B. An infant with diarrhea
- C. A 45-year-old with stomach flu
- D. An elderly patient living alone
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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.