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When you report on duty, your team leader tells you that Mr. MartineHi accidentally received 1000 ml of fluids in 2 hours and that you are to be alert for signs of circulatory overload. Which of the following signs would not be likely to occur?
- A. moist gurgling respirations
- B. Distended neck veins
- C. Weak, slow pulse
- D. Dyspnea and coughing
Correct Answer: C
Rationale: Circulatory overload is a condition where there is an excessive volume of fluid circulating in the bloodstream. Signs of circulatory overload include moist gurgling respirations, distended neck veins, dyspnea, and coughing. A weak, slow pulse would not be a typical sign of circulatory overload; in fact, it could indicate other conditions such as bradycardia or hypovolemia. Therefore, a weak, slow pulse would not likely occur as a sign of circulatory overload in this scenario.
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Which of the ff must the nurse consider when administering IV fluids to clients with hypertension?
- A. The nurse checks the clients BP every hour
- B. The nurse checks the site and progress of the infusion every hour
- C. The nurse checks the progress of the infusion once a day
- D. The nurse checks the client's pulse rate every hour
Correct Answer: B
Rationale: When administering IV fluids to clients with hypertension, the nurse must closely monitor the site and progress of the infusion every hour to ensure proper hydration and detect any signs of complications such as infiltration or infection. Checking the blood pressure every hour, as in choice A, may not be necessary unless specifically indicated by the healthcare provider. Checking the progress of the infusion once a day, as in choice C, does not provide adequate monitoring for a client with hypertension who may be at higher risk for fluid volume overload. Checking the client's pulse rate every hour, as in choice D, is important but does not directly address the immediate monitoring needs related to the administration of IV fluids.
A client who has been taking prednisone to treat lupus erythematosus has discontinued the medication because of lack of funds to buy the drug. When the nurse becomes aware of the situation, which assessment is most important for the nurse to make first?
- A. breath sounds
- B. blood pressure
- C. capillary refill
- D. butterfly rash
Correct Answer: B
Rationale: The most important assessment for the nurse to make first in this situation is the client's blood pressure. Abrupt discontinuation of prednisone, especially in a client with lupus erythematosus, can lead to adrenal insufficiency or an Addisonian crisis. Addisonian crisis can present with symptoms such as severe hypotension, fatigue, weakness, and even shock. Therefore, monitoring the client's blood pressure is crucial to assess for signs of adrenal insufficiency and to intervene promptly if needed. Once blood pressure is assessed, the nurse can then proceed to assess other parameters such as breath sounds, capillary refill, and the presence of a butterfly rash.
A 4 years old boy presents with low grade fever and malaise. Throat examination reveals a grayish white membrane which is tightly adherent and bleeds on an attempt to remove. The most likely diagnosis is:
- A. Acute Follicular tonsillitis
- B. Diphtheria
- C. Herpetic infection
- D. Infectious mononucleosis
Correct Answer: B
Rationale: Diphtheria causes a characteristic grayish-white membrane in the throat that bleeds when removed, along with systemic symptoms like fever and malaise.
A client is hospitalized with oat cell carcinoma of the lung. To manage severe pain, the physician prescribes a continuous I.V. infusion of morphine. Which formula should the nurse use to check that the morphine dose is appropriate for the client?
- A. 1 mg/kg of body weight
- B. 5 mg/70kg of body weight
- C. 5 mg/kg of body weight
- D. 10mg/70kg of body weight
Correct Answer: C
Rationale: When calculating the appropriate dose of morphine for a client, the nurse should consider the client's body weight. The most commonly used formula for calculating the appropriate dose of morphine is 0.1 to 0.2 mg/kg of body weight for hourly dosing or 2.5 to 10 mg/kg/day for continuous infusions.
The nurse needs to obtain blood for ongoing assessment of a high-risk newborn's progress. Which tests should the nurse monitor? (Select all that apply.)
- A. Blood glucose
- B. Complete blood count (CBC)
- C. Calcium
- D. Serum electrolytes
Correct Answer: A
Rationale: Blood glucose: Monitoring blood glucose levels is crucial in high-risk newborns to ensure they are within the normal range. High or low blood glucose levels can indicate various conditions that require prompt intervention.