Nokea
The nurse would expect which of the following would be included in the plan of care/
- A. Have the client drink at least 8 glases of water in the first day
- B. Administer NaHCO3 IV as per physician's orders
- C. Continue sodium bicarbonate for nausea
- D. Monitor electrolytes for hypokalemia and hypocalcemia
Correct Answer: D
Rationale: Monitoring electrolytes for hypokalemia (low potassium levels) and hypocalcemia (low calcium levels) is essential in the plan of care for a client. These electrolyte imbalances can be common in cases of dehydration and vomiting, and they can lead to serious complications if not detected and managed promptly. Hypokalemia can cause cardiac arrhythmias and muscle weakness, while hypocalcemia can lead to neuromuscular irritability and seizures. By monitoring electrolyte levels, the nurse can identify any imbalances early and take necessary interventions to prevent adverse outcomes.
You may also like to solve these questions
Which of the following nursing interventions will help prevent a further increase in ICP?
- A. Encourage fluids
- B. Provide physical therapy
- C. Elevate the head of the bed
- D. Reposition the patient frequently
Correct Answer: C
Rationale: Elevating the head of the bed helps to promote venous drainage from the brain, which can help reduce intracranial pressure (ICP). By positioning the patient with the head of the bed at a 30-45 degree angle, it can facilitate the circulation of cerebrospinal fluid and blood, thus preventing a further increase in ICP. This intervention is a crucial aspect of managing patients with increased ICP and can help improve their overall neurological status.
Which of the following nursing actions is appropriate when a patient returns to his or her room after a bronchoscopy?
- A. Order a meal because the patient has been nil per os (NPO) for 8 hours.
- B. Encourage fluids to flush dye from the patient's system.
- C. Monitor the patient for return to consciousness.
- D. Check for a gag reflex before allowing the patient to drink.
Correct Answer: D
Rationale: After a bronchoscopy procedure, it is essential to check for the presence of a gag reflex before allowing the patient to drink. This is crucial to prevent aspiration, as the gag reflex helps protect the airway by triggering swallowing and preventing foreign material from entering the lungs. Allowing the patient to drink without assessing the gag reflex could lead to serious complications such as aspiration pneumonia. Therefore, checking for the gag reflex is an appropriate nursing action to ensure the safety and well-being of the patient after a bronchoscopy.
The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: Pernicious anemia is a type of megaloblastic anemia caused by the body's inability to absorb vitamin B12, essential for the production of red blood cells. The characteristic findings associated with pernicious anemia include pallor due to decreased red blood cells, tachycardia as the heart compensates for decreased oxygen-carrying capacity, and a sore tongue (glossitis) due to vitamin B12 deficiency affecting the oral mucosa. Therefore, the nurse should expect to find pallor, tachycardia, and a sore tongue when assessing a client with pernicious anemia.
is softening of the bones as result of nutritional deficiencies or limited exposure to sunlight :
- A. COXA
- B. scoliosis
- C. Rickets
- D. Talipes
Correct Answer: C
Rationale: Rickets is a condition that involves softening and weakening of the bones in children, usually due to a vitamin D deficiency, inadequate calcium intake, or lack of exposure to sunlight. Vitamin D is essential for the absorption of calcium and phosphorus in the body, which are important for bone health. Without sufficient vitamin D, the body is unable to properly mineralize the bones, leading to softening and deformities. Common symptoms of rickets include bowed legs, delayed growth, and muscle weakness. Treatment typically involves vitamin D supplementation, dietary changes, and adequate exposure to sunlight.
The nurse understands that which of the ff. best describes the action of propanolol (Inderal)?
- A. It increases heart rate
- B. It decreases fluid volume
- C. It decreases cardiac output
- D. It increases cardiac contractility
Correct Answer: C
Rationale: Propranolol (Inderal) is a non-selective beta-blocker that works by blocking beta receptors in the heart and blood vessels. By blocking these receptors, propranolol decreases the effects of adrenaline, leading to a decrease in heart rate, blood pressure, and cardiac output. This results in a reduction in the workload of the heart, making it an effective medication for conditions such as hypertension, angina, and certain types of arrhythmias. Overall, the action of propranolol leads to a decrease in cardiac output, contrary to the options that suggest an increase in heart rate, fluid volume, or cardiac contractility.