Nokea
A young female with recent ileostomy due to ulcerative colitis. A middle-aged male with elevated temperature and chronic pancreatitis. A teenager in hypovolemic shock following a crushing injury to the chest. A child with compound fracture of the right femur and massive laceration of the left arm.
The nurse would identify which of the following patients as a likely candidate for developing acute renal failure?
- A. A young female with recent ileostomy due to ulcerative colitis.
- B. A middle-aged male with elevated temperature and chronic pancreatitis.
- C. A teenager in hypovolemic shock following a crushing injury to the chest.
- D. A child with compound fracture of the right femur and massive laceration of the left arm.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to acute renal failure. (1) usually ileostomy clients do not experience severe hypovolemia, which would lead to renal failure problems (2) this type of infection and inflammation does not lead to acute renal failure (3) correct-common cause of acute renal failure is renal ischemia precipitated by hypovolemia or heart failure (4) femoral fractures are more likely to lead to fat embolism than acute renal failure
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A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection.
The patient's preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment is to
- A. minimize the bacterial count in the mouth.
- B. soften the mucous membranes of the tongue before surgery.
- C. stimulate the microcirculation of the mouth.
- D. hydrate the tissues of the gums.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the procedure. (1) correct-destroys bacteria found in mouth, reduces the chance of infection (2) is not the action of hydrogen peroxide (3) circulation is unaffected by a mouth rinse (4) has slight drying effect on mucous membranes
The nurse auscultates bibasilar inspiratory crackles in a newly admitted 68 year-old client with a diagnosis of congestive heart disease. Which other finding is most likely to occur?
- A. Chest pain
- B. Peripheral edema
- C. Nail clubbing
- D. Lethargy
Correct Answer: B
Rationale: Peripheral edema. Bibasilar crackles and peripheral edema are common in congestive heart failure due to fluid overload.
A bipolar patient refuses to put down the mop that he is swinging to threaten other patients and staff.
What information is MOST important for the nurse to consider before administering a PRN IM dose of lorazepam (Ativan)?
- A. The patient is harmful to himself.
- B. The patient is psychotic.
- C. A restrictive intervention failed.
- D. The patient is harmful to others.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) use the least restrictive interventions in ascending order (2) use the least restrictive interventions in ascending order (3) correct-use the least restrictive interventions in ascending order (4) use the least restrictive interventions in ascending order
The nurse is caring for a client with a history of bipolar disorder who is receiving valproic acid (Depakote) 500 mg PO bid. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Liver enzymes elevated to twice normal.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: Elevated liver enzymes suggest hepatotoxicity, a serious side effect of valproic acid, requiring immediate evaluation to prevent liver failure. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.
The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously every 12 hours. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Platelet count of 100,000/mm^3.
- B. INR of 1.2.
- C. PTT of 40 seconds.
- D. Hemoglobin of 14 g/dL.
Correct Answer: A
Rationale: A platelet count of 100,000/mm^3 suggests thrombocytopenia, a serious complication of heparin therapy, increasing bleeding risk and possibly indicating heparin-induced thrombocytopenia. Options B, C, and D are normal or less concerning: INR and PTT are not significantly affected by subcutaneous heparin, and hemoglobin 14 g/dL is normal.