Nokea
The physician has ordered a peripheral IV to be inserted before the patient goes for computed tomography. What
should the nurse do when selecting a site on the hand or arm for insertion of an IV catheter?
- A. Choose a hairless site if available.
- B. Consider potential effects on the patients mobility when selecting a site.
- C. Have the patient briefly hold his arm over his head before insertion
- D. Leave the tourniquet on for at least 3 minutes.
Correct Answer: B
Rationale: The correct answer is B because considering potential effects on the patient's mobility is crucial when selecting a site for IV insertion. Mobility can be affected if the IV is placed in a joint area or on the dominant hand. This could limit the patient's ability to move freely during and after the procedure. Therefore, it is important to choose a site that will not hinder the patient's movement.
A: Choosing a hairless site is not the most important factor when selecting a site for IV insertion.
C: Having the patient hold his arm over his head before insertion is not necessary and may cause discomfort for the patient.
D: Leaving the tourniquet on for at least 3 minutes is not recommended as it can lead to complications such as venous stasis.
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You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the followin
- A. Diminished deep tendon reflexes
- B. Tachycardia
- C. Cool, clammy skin
- D. Acute flank pain
Correct Answer: A
Rationale: Step 1: High magnesium levels can lead to hypermagnesemia, which can cause decreased neuromuscular function.
Step 2: Diminished deep tendon reflexes are a sign of neuromuscular impairment, indicating potential hypermagnesemia.
Step 3: Assessing for diminished deep tendon reflexes is crucial to monitor neuromuscular function in patients with high magnesium levels.
Summary: A is correct because hypermagnesemia affects neuromuscular function. B, C, and D are incorrect as they do not directly relate to the effects of high magnesium levels.
The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The
nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at
125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift
assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates
decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom
would you expect this patient to exhibit
- A. Diarrhea
- B. Dilute urine
- C. Increased muscle tone
- D. Joint pain
Correct Answer: B
Rationale: The correct answer is B: Dilute urine. Hypokalemia can lead to kidney dysfunction, causing the kidneys to excrete more water along with electrolytes, resulting in dilute urine. This is a manifestation of the body's attempt to compensate for low potassium levels by excreting excess water. The other choices are incorrect because: A) Diarrhea is more commonly associated with hyperkalemia, not hypokalemia. C) Increased muscle tone is not a typical sign of hypokalemia; rather, hypokalemia can lead to muscle weakness or paralysis due to impaired muscle function. D) Joint pain is not a typical symptom of hypokalemia; joint pain is more commonly associated with other conditions such as arthritis or inflammation.
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that do not apply.)
- A. Hypokalemia Flaccid paralysis with respiratory depression
- B. Hyperphosphatemia Paresthesia with sensations of tingling and numbness
- C. . Hyponatremia Decreased level of consciousness
Correct Answer: B
Rationale: The correct answer is B because hyperphosphatemia can lead to paresthesia with sensations of tingling and numbness due to its effect on nerve function.
A, hypokalemia causes muscle weakness but not flaccid paralysis with respiratory depression.
C, hyponatremia typically presents with symptoms such as confusion and seizures, not decreased level of consciousness.
A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is
going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been
between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious
administering oxygen. What is the new nurses best response?
- A. The patients calcium will rise dramatically due to pituitary stimulation.
- B. Oxygen will increase the patients intracranial pressure and create confusion.
- C. Oxygen may cause the patient to hyperventilate and become acidotic.
- D. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
Correct Answer: D
Rationale: The correct answer is D: Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. In patients with chronic emphysema, their respiratory drive is often triggered by low oxygen levels rather than high carbon dioxide levels. Administering supplemental oxygen can suppress their respiratory drive, leading to carbon dioxide retention (carbon dioxide narcosis) and worsening hypoxemia. This phenomenon is known as "hypoxic drive."
Choice A is incorrect because administering oxygen does not lead to a dramatic rise in calcium levels due to pituitary stimulation. Choice B is incorrect because administering oxygen does not typically increase intracranial pressure or cause confusion. Choice C is incorrect because administering oxygen does not directly cause hyperventilation and acidosis in this scenario.
. A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in
renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability?
- A. The kidneys regulate and reabsorb carbonic acid to change and maintain pH.
- B. The kidneys buffer acids through electrolyte changes
- C. The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
- D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.
Correct Answer: C
Rationale: Rationale:
C is correct because in renal failure, the kidneys lose the ability to regenerate and reabsorb bicarbonate, which is essential for maintaining a stable pH level in the body. B is incorrect because the kidneys primarily regulate pH by controlling bicarbonate levels, not through electrolyte changes. A is incorrect because the kidneys do not regulate carbonic acid in the same way. D is incorrect as it does not accurately describe the process of pH regulation in the kidneys.