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The patient is admitted with complaints of general malaise and fatigue, along with a decreased urinary output. The patient’s urinalysis shows coarse, muddy brown granular casts and hematuria. The nurse determines that the patient has:
- A. acute kidney injury from a prerenal condition.
- B. acute kidney injury from postrenal obstruction.
- C. intrarenal disease, probably acute tubular necrosis.
- D. a urinary tract infection.
Correct Answer: C
Rationale: The correct answer is C: intrarenal disease, probably acute tubular necrosis. The patient's symptoms of general malaise, fatigue, decreased urinary output, along with the presence of coarse, muddy brown granular casts and hematuria in the urinalysis indicate kidney damage. Acute tubular necrosis is a common cause of acute kidney injury characterized by damage to the renal tubules, leading to impaired kidney function. The presence of granular casts and hematuria suggests tubular injury and bleeding within the kidney. Choices A and B are incorrect as they refer to prerenal and postrenal causes of kidney injury, respectively, which do not align with the patient's symptoms and urinalysis findings. Choice D is incorrect as a urinary tract infection would typically present with different symptoms and urinalysis findings.
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The patient’s potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction?
- A. Sodium polystyrene sulfonate
- B. Sodium polystyrene sulfonate with sorbitol
- C. Regular insulin
- D. Calcium gluconate
Correct Answer: C
Rationale: Correct Answer: C - Regular insulin
Rationale:
1. Insulin promotes cellular uptake of potassium.
2. When insulin is administered, it moves potassium from extracellular to intracellular space.
3. This decreases plasma potassium levels safely.
4. Other options do not directly lower potassium levels in the same manner.
Summary of Other Choices:
A: Sodium polystyrene sulfonate - exchanges sodium for potassium in the intestines, not reducing total body potassium.
B: Sodium polystyrene sulfonate with sorbitol - similar to A, does not reduce total body potassium.
D: Calcium gluconate - does not directly lower potassium levels, used for treating hyperkalemia-induced cardiac toxicity.
What is the main purpose of certification for critical care n ursing?
- A. To assure the consumer that critical nurses will not make a mistake.
- B. To help prepare the critical care nurse for graduate sch ool.
- C. To assist in promoting magnet status for a facility.
- D. To validate a nurse’s knowledge of critical care nursing
Correct Answer: D
Rationale: The correct answer is D: To validate a nurse’s knowledge of critical care nursing. Certification in critical care nursing validates a nurse's expertise and knowledge in this specialized area of nursing. It demonstrates that the nurse has met certain standards and competencies in critical care practice. This certification ensures that the nurse is well-equipped to provide high-quality care to critically ill patients.
A: To assure the consumer that critical nurses will not make a mistake - This choice is incorrect because certification does not guarantee that nurses will not make mistakes. It focuses on validating knowledge and skills rather than infallibility.
B: To help prepare the critical care nurse for graduate school - This choice is incorrect as certification is more focused on practice readiness rather than academic preparation.
C: To assist in promoting magnet status for a facility - This choice is incorrect as magnet status relates more to the overall excellence and quality of nursing care in a facility, not individual certification.
The nursing is caring for a patient who has had an arterial line inserted. To reduce the risk of complications, what is the priority nursing intervention?
- A. Apply a pressure dressing to the insertion site.
- B. Ensure all tubing connections are tightened.
- C. Obtain a portable x-ray to confirm placement.
- D. Restrain the affected extremity for 24 hours.
Correct Answer: C
Rationale: The correct answer is C: Obtain a portable x-ray to confirm placement. This is the priority intervention because it ensures the arterial line is correctly positioned, reducing the risk of complications such as dislodgement or improper placement. Applying a pressure dressing (choice A) may be necessary but is not the priority. Ensuring tubing connections are tightened (choice B) is important for preventing leaks but does not address placement. Restraining the affected extremity (choice D) is unnecessary and can lead to complications. The x-ray confirms correct placement, ensuring accurate monitoring and treatment.
The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should the nurse take?
- A. Withhold the medication and contact the healthcare provider.
- B. Give the medication dosage as scheduled.
- C. Assess respiratory rate for one minute next.
- D. Wait 30 minutes and give half of the dosage of medication.
Correct Answer: A
Rationale: The correct answer is A. Infants typically have higher resting heart rates than adults, so a pulse rate of 89 beats/minute for an infant may indicate bradycardia. Digoxin can further lower the heart rate, leading to potential adverse effects like arrhythmias. Therefore, withholding the medication and contacting the healthcare provider is crucial to ensure the safety of the infant.
Choice B is incorrect because administering digoxin without addressing the elevated pulse rate can be dangerous. Choice C is incorrect as assessing respiratory rate does not address the immediate concern of the elevated pulse rate. Choice D is also incorrect as waiting and giving half of the dosage may further exacerbate the situation.
The nurse is caring for a patient receiving benzodiazepine intermittently. What is the best way to administer such drugs?
- A. Medicate around the clock, rather than as needed, to en sure constant sedation.
- B. Administer the medications through the feeding tube to prevent complications.
- C. Give the highest allowable dose for the greatest effect.
- D. Titrate to a predefined endpoint using a standard sedat ion scale.
Correct Answer: D
Rationale: The correct answer is D: Titrate to a predefined endpoint using a standard sedation scale. This approach ensures individualized dosing based on the patient's response, minimizing the risk of over-sedation or under-treatment. It allows for careful monitoring and adjustment of dosage to achieve the desired level of sedation while avoiding adverse effects.
A: Administering medication around the clock may lead to unnecessary sedation and increased risk of side effects.
B: Administering medications through a feeding tube is not recommended for benzodiazepines as it may affect absorption and increase the risk of complications.
C: Giving the highest allowable dose without considering individual response can result in excessive sedation and adverse effects.