Nokea
What isotonic electrolyte solutions are COMMONLY used as fluid replacement in hypovolemic shock? I. Dextrose 5 percent in water II. 0.9 percent sodium chloride III. Lactated Ringer's solution IV. Dextrose 10 percent in water
- A. II, III, and IV
- B. II and III
- C. I, III, and IV
- D. I and IV
Correct Answer: B
Rationale: In hypovolemic shock, isotonic electrolyte solutions are commonly used for fluid replacement to restore the circulating blood volume. The commonly used isotonic electrolyte solutions for this purpose are 0.9% sodium chloride (normal saline) and lactated Ringer's solution.
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The mother asks why she has a gush of blood coming out from the vagina that occurs when she first arises from bed. The nurse's CORRECT response should be
- A. "Blood pools at the top of the vagina and forms clots that are passed upon rising or sitting on the toilet."
- B. "Positioning causes blood to flow out when she stands.
- C. "Because of the normal pooling of blood in the vagina when the woman lies down to rest or sleep."
- D. "Normal physiologic occurrence that results as the body attempts to eliminate excess fluids."
Correct Answer: C
Rationale: The correct response is "Because of the normal pooling of blood in the vagina when the woman lies down to rest or sleep." This phenomenon occurs due to gravity when a woman lies down, and the blood tends to pool at the top of the vagina. When she first arises from bed, the pooled blood is released, resulting in a gush of blood. This is a normal physiological process and not typically a cause for concern.
A postpartum client presents with sudden, severe chest pain and dyspnea. Which nursing action is most appropriate?
- A. Placing the client in a semi-Fowler's position
- B. Administering supplemental oxygen therapy
- C. Notifying the healthcare provider immediately
- D. Encouraging the client to perform deep breathing exercises
Correct Answer: C
Rationale: Sudden, severe chest pain and dyspnea in a postpartum client could be indicative of a potential serious condition, such as a pulmonary embolism or postpartum cardiomyopathy, which require immediate medical attention. Therefore, the most appropriate nursing action would be to notify the healthcare provider immediately for further evaluation and management. Placing the client in a semi-Fowler's position may provide some comfort but does not address the underlying cause of the symptoms. Administering supplemental oxygen therapy may be necessary once the healthcare provider assesses the client. Encouraging deep breathing exercises may not be appropriate if the client is experiencing severe chest pain and dyspnea, as it could worsen the situation.
While preparing the operating room (OR) for a surgical procedure, the nurse notices that the surgical instrument tray is incomplete. What should the nurse do?
- A. Proceed with the procedure using the available instruments
- B. Document the missing instruments in the surgical count log
- C. Inform the sterile processing department and request additional instruments
- D. Borrow the missing instruments from another OR Professionalism and Fundamentals of Nursing
Correct Answer: C
Rationale: It is crucial to have a complete set of surgical instruments for any surgical procedure to ensure patient safety and the success of the surgery. If the nurse notices that the surgical instrument tray is incomplete, the best course of action is to inform the sterile processing department immediately. By doing so, the missing instruments can be promptly provided, ensuring that the surgical team has all the necessary tools for the procedure. Proceeding with the procedure using incomplete instruments can compromise patient safety and the quality of care provided. Documenting the missing instruments in the surgical count log is important for record-keeping purposes but should not delay the immediate action of requesting additional instruments. Borrowing instruments from another OR is not recommended as it can create confusion, potential cross-contamination, and disrupt the workflow of another surgical team.
A patient presents with progressive hearing loss, tinnitus, and vertigo. Audiometric testing reveals sensorineural hearing loss with a "carrot-shaped" configuration. Which of the following conditions is most likely responsible for this presentation?
- A. Presbycusis
- B. Noise-induced hearing loss
- C. Ménière's disease
- D. Acoustic neuroma
Correct Answer: C
Rationale: Ménière's disease is characterized by the triad of symptoms including progressive sensorineural hearing loss, tinnitus, and vertigo. The audiometric testing in Ménière's disease often shows a "carrot-shaped" configuration, which refers to low-frequency hearing loss initially and eventually spreading to involve higher frequencies. This distinctive pattern of hearing loss helps differentiate Ménière's disease from other causes like Presbycusis (age-related hearing loss) or Noise-induced hearing loss. Acoustic neuroma can present with unilateral sensorineural hearing loss but typically does not exhibit the specific "carrot-shaped" configuration seen in Ménière's disease.
A nurse is preparing to assist with a cardiopulmonary exercise stress test for a patient. What action should the nurse prioritize to ensure patient safety during the test?
- A. Administering a beta-blocker medication to the patient before the test
- B. Monitoring the patient's electrocardiogram (ECG) rhythm continuously during the test
- C. Encouraging the patient to consume a heavy meal two hours before the test
- D. Allowing the patient to resume normal activities immediately after the test
Correct Answer: B
Rationale: The most critical action to prioritize for ensuring patient safety during a cardiopulmonary exercise stress test is to monitor the patient's electrocardiogram (ECG) rhythm continuously during the test (Option B). This monitoring allows the healthcare team to promptly detect any abnormal heart rhythms or signs of cardiac distress, enabling timely intervention if necessary. Continuous ECG monitoring is essential during exercise testing as it helps in assessing the heart's response to physical activity and identifying any potential cardiac abnormalities or complications that may arise during the test. By closely monitoring the ECG rhythm, the nurse can ensure the patient's safety and well-being throughout the procedure. Administering a beta-blocker medication before the test (Option A) may be indicated in some cases but is not as crucial as continuous ECG monitoring during the test. Encouraging the patient to consume a heavy meal before the test (Option C) is contraindicated as it can interfere with the accuracy of the results