Nokea
What does progression of patients through various phases of care in a postanesthesia care unit (PACU) primarily depend on?
- A. Condition of patient
- B. Type of anesthesia used
- C. Preference of surgeon
- D. Type of surgical procedure
Correct Answer: A
Rationale: Patient condition dictates the progression through PACU phases, ensuring appropriate care levels.
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Derek has recently converted his outdoor garage to a gym. He has been exercising frequently in his new gym due to the convenience, even in the extreme heat. He has started taking salt tablets. The physician thinks his current symptoms may be owing to hypernatremia. His physician recognizes these as:
- A. Cardiac arrhythmias,palpitations and sinus arrest.
- B. Weakness,dizziness,abdominal distention, nausea ,vomiting, and diarrhea.
- C. Weight gain,irritability,muscle twitching and decreased myocardial contractility.
- D. Muscle cramps,malaise,constipation,rhabdomyolysis and pupillary constriction.
Correct Answer: B
Rationale: The correct answer is Weakness, dizziness, abdominal distention, nausea, vomiting, and diarrhea (B). Hypernatremia occurs when there is an excess of sodium in the body, often due to dehydration or excessive salt intake. Symptoms include gastrointestinal disturbances, neurological symptoms like confusion and dizziness, and muscle weakness.
The following data are organized according to Gordon’s functional health patterns.
- A. 78-year-old woman
- B. Married, three grown children who all live out of town
- C. Cares for invalid husband in home with help of daily homemaker
- D. Vision corrected with glasses; hearing normal
Correct Answer: A
Rationale: N/A
Until Mr. Jones’ diagnosis is confirmed, what should be a priority?
- A. Encouraging rest
- B. Monitoring intake and output
- C. Preventing spread of infection to others
- D. Providing attractive meals
Correct Answer: C
Rationale: The correct answer is C: Preventing spread of infection to others. This is the priority because until Mr. Jones' diagnosis is confirmed, it is crucial to prevent potential transmission of any infectious diseases to others. Encouraging rest (choice A) and providing attractive meals (choice D) are important for overall well-being but not as critical as preventing the spread of infection. Monitoring intake and output (choice B) is important for assessing Mr. Jones' health status but does not directly address the potential risk of infecting others. Therefore, choice C is the most immediate priority to ensure the safety of others.
When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?
- A. Raise the affected extremity above the level of the heart.
- B. Immobilize the affected extremity with a splint
- C. Apply ice to the bite area
- D. Apply a tourniquet to the affected extremity.
Correct Answer: B
Rationale: The correct answer is B: Immobilize the affected extremity with a splint. This is important to prevent the spread of venom through the lymphatic system. Elevating the extremity (A) can increase the spread of venom. Applying ice (C) can constrict blood vessels, trapping venom in the area. Applying a tourniquet (D) can lead to tissue damage and worsen the condition. Immobilizing with a splint is the most effective way to limit movement and venom spread.
The physician has written orders for the client with Excess Fluid Volume. The client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
- A. Weigh client every morning
- B. Maintain accurate intake and output
- C. Restrict fluid to 1500 mL per day
- D. Administer furosemide (Lasix) 40 mg IV push
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide (Lasix) 40 mg IV push. This is the priority because the client is showing signs of fluid volume excess, such as weight gain, pitting edema, and crackles, which indicate fluid overload in the lungs. Furosemide is a loop diuretic that helps to remove excess fluid from the body quickly, making it crucial in managing excess fluid volume in this situation. Weighing the client daily (A) is important but not as urgent as addressing the immediate symptoms of fluid overload. Maintaining accurate intake and output (B) is essential for overall fluid balance but does not address the immediate excess fluid volume. Fluid restriction (C) may be needed in the long term, but immediate intervention with furosemide is necessary to prevent worsening of symptoms and potential complications.