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Victorio is being managed for diarrhea. Which outcome indictes that fluid resuscitation is successful?
- A. he passess formed stools at regular intervals
- B. he reports a decrease in stool frequency and liquidity
- C. he exhibits frim skin turgor
- D. he no longer experiences perianal burning
Correct Answer: C
Rationale: The correct answer is C because firm skin turgor indicates adequate hydration, a key goal of fluid resuscitation in diarrhea management. Firm skin turgor reflects the body's fluid balance and hydration status. When fluid resuscitation is successful, the patient's skin turgor improves due to replenished fluid levels. Choices A, B, and D are incorrect as they do not directly assess hydration status or the effectiveness of fluid resuscitation. Passing formed stools, decrease in stool frequency, and absence of perianal burning may be positive outcomes in diarrhea management, but they do not specifically indicate successful fluid resuscitation.
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A client with advanced breast cancer is prescribed tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
- A. Vision changes
- B. Headache
- C. Hearing loss
- D. Anorexia
Correct Answer: A
Rationale: The correct answer is A: Vision changes. Tamoxifen can cause serious ocular side effects like retinopathy and corneal changes. These adverse reactions can lead to vision impairment or loss, which is crucial to report immediately to prevent permanent damage. Headache (B), hearing loss (C), and anorexia (D) are not typically associated with tamoxifen use and do not pose immediate threats to the client's health compared to vision changes. It is important for the nurse to prioritize educating the client on recognizing and reporting vision changes promptly to ensure timely intervention and prevent irreversible consequences.
Mr. Reyea complains of hearing ringing noises. The nurse recognizes that this assessment suggests injury of the
- A. Frontal lobe
- B. Six cranial nerve (abducent)
- C. Occipital lobe
- D. Eight Cranial Nerve (Vestibulocochlear)
Correct Answer: D
Rationale: The correct answer is D: Eight Cranial Nerve (Vestibulocochlear). This nerve is responsible for hearing and balance. Ringing noises indicate a disturbance in hearing function. The other choices are incorrect because: A: Frontal lobe is associated with executive functions, not hearing. B: Six cranial nerve (abducent) controls eye movement. C: Occipital lobe is related to vision, not hearing. Therefore, the correct choice is D as it directly relates to the symptom described.
For a client in addisonian crisis, it would be very risky for a nurse to administer:
- A. potassium chloride.
- B. hydrocortisone.
- C. normal saline solution
- D. fludrocortisone.
Correct Answer: A
Rationale: The correct answer is A: potassium chloride. In Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone. Potassium levels are typically elevated in Addisonian crisis due to decreased aldosterone. Administering potassium chloride can further increase potassium levels, leading to life-threatening cardiac arrhythmias. Hydrocortisone (B) is essential to replace cortisol, normal saline solution (C) helps with volume resuscitation, and fludrocortisone (D) replaces aldosterone. Administering potassium chloride would exacerbate the hyperkalemia in Addisonian crisis.
The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level:
- A. Below 70mg/dl
- B. Between 70 and 120mg/dl
- C. Between 120 and 180mg/dl
- D. Over 180mg/dl A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET P
Correct Answer: A
Rationale: The correct answer is A, below 70mg/dl, for a hypoglycemic client. Hypoglycemia is defined as low blood glucose levels, typically below 70mg/dl. Symptoms of hypoglycemia include confusion, sweating, shakiness, and palpitations. Treating hypoglycemia involves providing the client with a fast-acting source of glucose to raise their blood sugar levels quickly. Choices B, C, and D are incorrect as they indicate normal or elevated blood glucose levels, which are not characteristic of hypoglycemia. It is crucial for the nurse to recognize and promptly address hypoglycemia to prevent potential complications.
The first thing to do for a nurse when an accident occurs is to find out if patient is conscious so that she could:
- A. Reassure the patient
- B. Call relatives
- C. Bring patient immediately to the hospital
- D. Call a doctor
Correct Answer: A
Rationale: The correct answer is A: Reassure the patient. The first priority in any accident scenario is to ensure the patient's safety and well-being. By checking if the patient is conscious, the nurse can assess their immediate condition and provide reassurance to alleviate any distress or anxiety. This step establishes communication and trust, allowing for further assessment and appropriate actions to be taken. Calling relatives (B) may be important but not the immediate first step. Bringing the patient immediately to the hospital (C) is premature without assessing the patient first. Calling a doctor (D) can be done after assessing the patient's condition.