The removal of plasma water and some low–molecular weight particles by using a pressure or osmotic gradient is known as
- A. dialysis.
- B. diffusion.
- C. clearance.
- D. ultrafiltration.
Correct Answer: D
Rationale: The correct answer is D: ultrafiltration. Ultrafiltration involves the removal of plasma water and low-molecular weight particles using a pressure or osmotic gradient. This process allows small molecules to pass through a semipermeable membrane while retaining larger molecules. Dialysis (A) involves the removal of waste products and excess fluids from the blood, while diffusion (B) is the movement of molecules from an area of high concentration to low concentration. Clearance (C) refers to the rate at which a substance is removed from the blood by a specific organ or process. Ultrafiltration specifically targets the removal of plasma water and low-molecular weight particles through a pressure or osmotic gradient, making it the correct choice in this context.
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The nurse is caring for a patient with head trauma who was admitted to the surgical intensive care unit following a motorcycle crash. What is an important assessment that will assist the nurse in early identification of an endocrine disorder commonly associated with this condition?
- A. Daily weight
- B. Fingerstick glucose
- C. Lung sound auscultation
- D. Urine osmolality
Correct Answer: D
Rationale: The correct answer is D: Urine osmolality. In head trauma patients, the risk of developing diabetes insipidus (DI) is high due to damage to the posterior pituitary. Monitoring urine osmolality helps identify DI early, as low urine osmolality indicates impaired concentration ability. This is crucial for prompt treatment to prevent dehydration. Choices A and B are important but not specific to endocrine disorders. Choice C is relevant for respiratory assessment, not endocrine disorders.
Which of the following are appropriate nursing interventions for the patient in myxedema coma? (Select all that apply.)
- A. Administer levothyroxine as prescribed.
- B. Encourage the intake of foods high in sodium.
- C. Initiate passive rewarming interventions.
- D. Monitor airway and respiratory effort.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Administering levothyroxine is crucial in treating myxedema coma as it helps replace the deficient thyroid hormone.
2. This intervention addresses the underlying cause of myxedema coma, which is severe hypothyroidism.
3. Levothyroxine administration can help reverse the symptoms of myxedema coma and improve the patient's condition.
Summary of Incorrect Choices:
- B: Encouraging high sodium intake is not appropriate as myxedema coma is associated with fluid retention and sodium may exacerbate this.
- C: Passive rewarming interventions are not relevant for myxedema coma, as the condition is not typically related to hypothermia.
- D: While monitoring airway and respiratory effort is important in general patient care, it is not a specific intervention for myxedema coma.
The nurse is caring for a patient who has undergone major abdominal surgery. The nurse notices that the patient’s urine output has been less than 20 mL/hour for the past 2 hours. The patient’s blood pressure is 100/60 mm Hg, and the pulse is 110 beats/min. Previously, the pulse was 90 beats/min with a blood pressure of 120/80 mm Hg. The nurse should
- A. contact the provider and expect a prescription for a normal saline bolus.
- B. wait until the provider makes rounds to report the assessment findings.
- C. continue to evaluate urine output for 2 more hours.
- D. ignore the urine output, as this is most likely postrenal in origin.
Correct Answer: A
Rationale: Rationale:
1. Urine output < 20 mL/hour indicates potential hypoperfusion.
2. Decreased urine output with hypotension and tachycardia suggests inadequate fluid resuscitation.
3. Administering a normal saline bolus can help improve perfusion and stabilize blood pressure.
4. Contacting the provider promptly for orders is crucial in managing this acute situation.
Summary of Incorrect Choices:
B. Delaying reporting to the provider risks worsening the patient's condition.
C. Continuing to evaluate urine output without intervention can lead to further deterioration.
D. Ignoring the urine output due to potential postrenal causes overlooks the urgent need for fluid resuscitation.
Which of the following patients is at the highest risk for hyperosmolar hyperglycemic syndrome?
- A. An 18-year-old college student with type 1 diabetes who exercises excessively
- B. A 45-year-old woman with type 1 diabetes who forgets to take her insulin in the morning
- C. A 75-year-old man with type 2 diabetes and coronary artery disease who has recently started on insulin injections
- D. An 83-year-old, long-term care resident with type 2 diabetes and advanced Alzheimer’s disease who recently developed influenza
Correct Answer: D
Rationale: The correct answer is D because the 83-year-old long-term care resident with type 2 diabetes and advanced Alzheimer's disease who recently developed influenza is at the highest risk for hyperosmolar hyperglycemic syndrome (HHS). This patient has multiple risk factors for HHS, including age, type 2 diabetes, advanced Alzheimer's disease, and the added stress of influenza, which can exacerbate hyperglycemia. The combination of these factors can lead to severe hyperglycemia, dehydration, and electrolyte imbalances characteristic of HHS.
Choice A is incorrect because although excessive exercise can lead to hypoglycemia in individuals with type 1 diabetes, it is not a risk factor for HHS. Choice B is incorrect as forgetting to take insulin can lead to diabetic ketoacidosis in type 1 diabetes, not HHS. Choice C is incorrect as starting insulin injections in a patient with type 2 diabetes and coronary artery disease does not automatically increase the risk
The patient undergoes a cardiac catheterization that requires the use of contrast dyes during the procedure. To detect signs of contrast-induced kidney injury, the nurse should
- A. not be concerned unless urine output decreases.
- B. evaluate the patient’s serum creatinine for up to 72 hours after the procedure.
- C. obtain an order for a renal ultrasound.
- D. evaluate the patient’s postvoid residual volume to detect intrarenal injury.
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Contrast dyes can cause kidney injury due to their nephrotoxic effects.
2. Serum creatinine levels are a reliable indicator of kidney function.
3. Evaluating serum creatinine for up to 72 hours after the procedure allows detection of any contrast-induced kidney injury.
4. Monitoring serum creatinine helps in early identification and intervention for renal complications.
Summary:
A: Incorrect. Urine output alone is not a definitive indicator of kidney injury.
C: Incorrect. Renal ultrasound is not typically used for detecting contrast-induced kidney injury.
D: Incorrect. Postvoid residual volume is not specific for contrast-induced kidney injury.
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