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: Step 1: Monitoring electrolytes is essential to assess for potential imbalances due to the use of sodium bicarbonate, which can lead to hypokalemia and hypocalcemia.
Step 2: Hypokalemia and hypocalcemia can result in serious complications such as cardiac arrhythmias and muscle weakness.
Step 3: By monitoring electrolytes, the nurse can detect imbalances early and intervene promptly to prevent adverse effects.
Summary:
A: Drinking excessive water can lead to electrolyte imbalances and is not directly related to the use of sodium bicarbonate.
B: Administering NaHCO3 IV is not within the nurse's scope of practice and should be done based on physician's orders.
C: Continuing sodium bicarbonate for nausea may not be appropriate without monitoring electrolytes to prevent potential imbalances.
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A nurse conducts an assessment and notes that the client has abnormal breath sounds, a productive cough, and cyanotic lips. How should the nurse categorize these findings?
- A. Subjective data
- B. Objective data
- C. Secondary data
- D. Primary data
Correct Answer: B
Rationale: The correct answer is B: Objective data. Abnormal breath sounds, a productive cough, and cyanotic lips are all observable and measurable findings that can be verified by the nurse through assessment. Objective data refers to information that can be observed or measured, providing concrete evidence of the client's condition. In this case, the nurse directly perceives these physical signs during the assessment, making them objective data.
Summary:
- A: Subjective data involves the client's feelings or opinions, which are not directly observable by the nurse.
- C: Secondary data are information obtained from other sources, not directly from the client.
- D: Primary data are firsthand information collected directly from the client, but in this scenario, the findings are observable physical signs, making them objective data.
The most effective pharmacologic agent for the treatment of Parkinson’s disease is:
- A. Levodopa
- B. Selegilene
- C. Permax
- D. Symmetrel
Correct Answer: A
Rationale: The correct answer is A: Levodopa. Levodopa is the most effective pharmacologic agent for treating Parkinson's disease because it is converted to dopamine in the brain, replenishing the deficient dopamine levels in Parkinson's patients. Selegiline and Symmetrel are also used in treating Parkinson's, but they are typically used as adjunctive therapy rather than the primary treatment. Permax has been withdrawn from the market due to safety concerns, making it an incorrect choice.
Which of the following statements about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. Administer 2 to 3L of IV fluid rapidly
- B. Administer 6L of IV fluid over the first 24 hours
- C. Administer a dextrose solution containing normal saline solution
- D. Administer IV fluid slowly to prevent circulatory overload and collapse
Correct Answer: B
Rationale: The correct answer is B: Administer 6L of IV fluid over the first 24 hours. In HHNS, dehydration is severe due to high blood glucose levels causing osmotic diuresis. Rapid infusion of fluid can lead to fluid overload and exacerbate the situation. Administering 6L over 24 hours helps gradually replenish lost fluids without causing circulatory overload. Choice A is incorrect because rapid infusion can lead to fluid overload. Choice C is incorrect because adding dextrose to the solution can further increase blood glucose levels. Choice D is incorrect because administering IV fluids slowly can delay rehydration in a critical situation like HHNS.
The nurse is taking vital signs of a pregnant woman during her first prenatal visit. The patient asks the nurse if she has to have an HIV test. Which of the following is the nurse’s best response?
- A. “Yes, all pregnant women must have the test.”
- B. “If you do not have multiple sex partners or inject drugs, it is not necessary.”
- C. “Governmental guidelines require an HIV test for all pregnant woman.”
- D. “After voluntary pretest counseling, you decide whether HIV testing should be done.”
Correct Answer: A
Rationale: Rationale for Correct Answer (A): The nurse's best response is to inform the pregnant woman that all pregnant women must have an HIV test. This is because HIV testing is a standard part of prenatal care to prevent mother-to-child transmission. It is crucial to detect HIV early to provide appropriate treatment and prevent transmission to the baby.
Summary of Incorrect Choices:
B: This response could lead to misinformation and potentially harm the patient and her baby. HIV testing is recommended for all pregnant women regardless of risk factors.
C: While governmental guidelines may vary, it is essential for all pregnant women to undergo HIV testing to ensure the health of both the mother and the baby.
D: While it is important to provide counseling and involve the patient in decision-making, in the case of HIV testing during pregnancy, it is a standard procedure that should be offered to all pregnant women to safeguard their health and that of their baby.
Which diagnosis will the nurse document in a patient’s care plan that is NANDA-I approved?
- A. Sore throat
- B. Acute pain
- C. Sleep apnea
- D. Heart failure
Correct Answer: B
Rationale: The correct answer is B: Acute pain. The rationale is that NANDA-I (North American Nursing Diagnosis Association-International) approves nursing diagnoses that are specific, measurable, and relevant to nursing care. Acute pain fits these criteria as it is a common nursing diagnosis that can be assessed objectively and treated with nursing interventions. The other choices (sore throat, sleep apnea, heart failure) are medical diagnoses that do not fall under the scope of nursing diagnoses approved by NANDA-I. Therefore, acute pain is the most appropriate diagnosis to be documented in a patient's care plan according to NANDA-I guidelines.