Nokea
What would be the best initial nursing actions prior to inserting an IV?
- A. Have the patient wash the hands.
- B. Prepare the IV insertion site with povidone iodine.
- C. Verify the order for IV therapy.
- D. Identify a suitable vein.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A nurse in the medical-surgical unit is giving a patient with low blood pressure a hypertonic solution, which will increase the number of dissolved particles in his blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Which of the following terms is associated with this process?
- A. Hydrostatic pressure
- B. Osmosis and osmolality
- C. Diffusion
- D. Active transport
Correct Answer: B
Rationale: Osmosis is the movement of fluid from a region of low solute concentration to a region of high solute concentration across a semipermeable membrane. The number of dissolved particles contained in a unit of fluid determines the osmolality of a solution, which influences the movement of fluid between the fluid compartments. Giving a patient who has a low blood pressure a hypertonic solution will increase the number of dissolved particles in the blood, creating pressure for fluids in the tissues to shift into the capillaries and increase the blood volume. Option A is incorrect; hydrostatic pressure refers to changes in water or volume related to water pressure. Option C is incorrect; diffusion is the movement of solutes from an area of greater concentration to lesser concentration. The solutes in an intact vascular system are unable to move, so diffusion should not normally take place. Option D is incorrect; active transport is the movement of molecules against the concentration gradient and requires ATP as an energy source. This process typically takes place at the cellular level and is not involved in vascular volume changes.
Your patient has alcoholism, and you may suspect during your assessment that his serum magnesium is low. What will the nurse potentially expect to assess related to hypomagnesemia?
- A. Tremor
- B. Pruritus
- C. Edema
- D. Decreased blood pressure
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 73-year-old man who slipped on a small carpet in his home and fell on his hip is alert and oriented; PERRLA (pupils equally round and reactive to light and accommodation) is intact, and he has come by ambulance to the emergency department (ED). Heart rate elevated, he is anxious and thirsty. A Foley catheter is in place and 40mL of urine is present. The nurse's most likely explanation for the urine output is:
- A. The man urinated prior to his arrival in the ED and will probably not need to have the Foley catheter kept in place.
- B. The man has a brain injury, lacks ADH, and needs vasopressin.
- C. The man is in heart failure and is releasing atrial natriuretic peptide, which results in decreased urine output.
- D. He is having a sympathetic reaction, which has stimulated the renin-angiotensin-aldosterone system that results in diminished urine output.
Correct Answer: D
Rationale: Renin is released by the juxtaglomerular cells of the kidneys in response to decreased renal perfusion. Angiotensin-converting enzyme converts angiotensin I to angiotensin II. Angiotensin II, with its vasoconstrictor properties, increases arterial perfusion pressure and stimulates thirst. As the sympathetic nervous system is stimulated, aldosterone is released in response to an increased release of renin, which decreases urine production. Based on the nursing assessment and mechanism of injury, this is the most likely cause of the lower urine output.
A nurse admitting a patient with a history of emphysema reviews her past lab reports and notes that the patient's PaCO2 has been 56 to 64 mmHg. The nurse will be cautious administering oxygen because:
- A. The patient's calcium will rise dramatically due to pituitary stimulation.
- B. The oxygen will increase the patient's intracranial pressure and create confusion.
- C. The 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: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a postthyroidectomy patient at risk for hypocalcemia. What action should the nurse take when assessing for hypocalcemia?
- A. Monitor laboratory values daily for an elevated thyroid-stimulating hormone.
- B. Observe for swelling of the neck, tracheal deviation, and severe pain.
- C. Evaluate the quality of the patient's voice postoperatively, noting any drastic changes.
- D. Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes.
Correct Answer: D
Rationale: Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia. The other options describe complications the nurse should also be observing for; however, tetany and neurologic alterations are primary indications of hypocalcemia.