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The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient’s urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has:
- A. acute kidney injury from a prerenal condition.
- B. acute kidney injury from postrenal obstruction.
- C. intrarenal disease, probably acute tubular necrosis.
- D. a urinary tract infection.
Correct Answer: C
Rationale: The correct answer is C: intrarenal disease, probably acute tubular necrosis. The patient's symptoms of general malaise, fatigue, decreased urinary output, along with the presence of coarse, muddy brown granular casts and hematuria in the urinalysis indicate kidney damage. Acute tubular necrosis is a common cause of acute kidney injury characterized by damage to the renal tubules, leading to impaired kidney function. The presence of granular casts and hematuria suggests tubular injury and bleeding within the kidney. Choices A and B are incorrect as they refer to prerenal and postrenal causes of kidney injury, respectively, which do not align with the patient's symptoms and urinalysis findings. Choice D is incorrect as a urinary tract infection would typically present with different symptoms and urinalysis findings.
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A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?
- A. Contact a grief counselor as soon as possible.
- B. Cry along with the patient’s family members.
- C. Leave the home as soon as possible to allow the family to grieve privately.
- D. Consider whether working in hospice is desirable because patient losses are common.
Correct Answer: B
Rationale: The correct answer is B: Cry along with the patient’s family members. This action demonstrates empathy and support for the family's grief, showing that the nurse acknowledges and shares their feelings. It can help the family feel understood and supported during a difficult time. By crying with the family, the nurse can validate their emotions and provide comfort without intruding on their personal space. This approach fosters a sense of connection and trust between the nurse and the family, enhancing the quality of care provided.
Incorrect Choices:
A: Contact a grief counselor as soon as possible - This choice may be premature and could come across as impersonal or distancing in the immediate aftermath of the patient’s death.
C: Leave the home as soon as possible - This choice would be insensitive and could make the family feel abandoned in their time of need.
D: Consider whether working in hospice is desirable because patient losses are common - This choice is inappropriate as it suggests the nurse should reconsider their career choice based on emotional reactions,
A 22-year-old patient who experienced a near-drowning accident in a local pool, but now is awake and breathing spontaneously, is admitted for observation. Which assessment will be most important for the nurse to take during the observation period?
- A. Auscultate heart sounds.
- B. Palpate peripheral pulses.
- C. Auscultate breath sounds.
- D. Check pupil reaction to light.
Correct Answer: C
Rationale: The correct answer is C: Auscultate breath sounds. After a near-drowning incident, the main concern is potential respiratory complications such as aspiration pneumonia or pulmonary edema. Auscultating breath sounds will help the nurse assess for any signs of respiratory distress or complications. This assessment is crucial for early detection and intervention.
A: Auscultating heart sounds is important but not as crucial as assessing breath sounds in this scenario.
B: Palpating peripheral pulses is important for circulation assessment but does not address the immediate concern of respiratory complications.
D: Checking pupil reaction to light is more relevant for neurological assessment and not as critical as assessing breathing in this situation.
Intrapulmonary shunting refers to what outcome?
- A. Alveoli that are not perfused.
- B. Blood that is shunted from the left side of the heart to t he right and causes heart failure.
- C. Blood that is shunted from the right side of the heart to the left without oxygenation.
- D. Shunting of blood supply to only one lung.
Correct Answer: C
Rationale: Step-by-step rationale for why choice C is correct:
1. Intrapulmonary shunting refers to blood bypassing the normal oxygenation process in the lungs.
2. Choice C describes blood being shunted from the right side of the heart (deoxygenated blood) to the left side without oxygenation, leading to systemic circulation without oxygenation.
3. Choices A, B, and D do not accurately describe intrapulmonary shunting as they focus on other concepts like alveolar perfusion, heart failure, and unilateral lung blood supply, respectively.
What is an early signs of the effect of hypoxemia on the nervous system?
- A. Cyanosis
- B. Restlessness
- C. Tachycardia
- D. Tachypnea
Correct Answer: B
Rationale: The correct answer is B: Restlessness. When the body experiences hypoxemia (low oxygen levels), the brain is deprived of oxygen, leading to early signs such as restlessness. This is due to the brain's attempt to increase oxygen intake by increasing activity. Cyanosis (A) is a late sign of hypoxemia when oxygen levels are critically low. Tachycardia (C) and tachypnea (D) are compensatory mechanisms in response to hypoxemia, but they are not early signs affecting the nervous system directly.
Which assessment would cue the nurse to the potential of aa bc iru bt .ce o mre /ts ep sti ratory distress syndrome (ARDS) in a patient admitted with respiratory distress?
- A. Increased oxygen saturation via pulse oximetry
- B. Increased peak inspiratory pressure on the ventilator
- C. Normal chest radiograph with enlarged cardiac structures
- D. PaO /FiO ratio > 300 2 2
Correct Answer: B
Rationale: The correct answer is B. Increased peak inspiratory pressure on the ventilator would cue the nurse to the potential of ARDS in a patient with respiratory distress. ARDS is characterized by severe respiratory failure with bilateral pulmonary infiltrates. An increase in peak inspiratory pressure on the ventilator indicates that the lungs are becoming stiffer, which is a common finding in ARDS due to increased inflammation and fluid accumulation in the alveoli. This finding alerts the nurse to the possibility of ARDS and the need for further assessment and intervention.
Summary of other choices:
A: Increased oxygen saturation via pulse oximetry is a nonspecific finding and may not specifically indicate ARDS.
C: Normal chest radiograph with enlarged cardiac structures is more indicative of heart failure rather than ARDS.
D: PaO2/FiO2 ratio > 300 is a criterion used to diagnose ARDS, but a value higher than 300 actually indicates mild ARDS, so it would not necessarily cue the nurse