Nokea
Which fluid replacement therapy would the nurse prepare to administer for a patient who is exhibiting clinical manifestations of hypovolemic shock?
- A. 0.459% saline.
- B. 0.9% NaCl.
- C. 5% dextrose in 0.45% saline.
- D. Dextran.
Correct Answer: B
Rationale: 0.9% NaCl (normal saline) is an isotonic solution ideal for hypovolemic shock, expanding intravascular volume without causing fluid shifts.
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Which phrase describes the function of a buffer?
- A. To excrete weak acids.
- B. To secrete hydrogen ions.
- C. To convert strong acids to weak acids.
- D. To convert ammonia to ammonium ions.
Correct Answer: C
Rationale: Buffers convert strong acids to weak acids by neutralizing them, helping maintain stable pH in bodily fluids.
A healthy 70-year-old patient has low hemoglobin levels and no signs of gastrointestinal bleeding. The nurse recognizes which item is an effect of aging that could be the reason for the low hemoglobin level?
- A. Low level of hepcidin.
- B. Increase in iron-binding capacity.
- C. Decrease in intestinal absorption of iron.
- D. Decrease in erythropoietin secretion from the kidneys.
Correct Answer: C
Rationale: Aging often leads to a decrease in the efficiency of nutrient absorption, including iron. This decrease in intestinal absorption of iron can result in low hemoglobin levels in elderly individuals. It's a common cause of anemia in the elderly population.
Which rationale supports the nurse's assessment of a patient's magnesium level?
- A. The electrolyte is the most abundant intracellular cation present in the body.
- B. The electrolyte may cause extracellular fluid overload.
- C. Magnesium may affect neuromuscular excitability and contractility.
- D. The patient is at risk for hypotension when the levels of magnesium decrease.
Correct Answer: C
Rationale: Magnesium plays a crucial role in neuromuscular excitability and contractility. Abnormal magnesium levels can lead to neuromuscular symptoms such as muscle weakness, tremors, and spasms, and affect cardiac function.
The arterial blood gas (ABG) results for a patient who overdosed on barbiturates are pH = 7.32, PaCO2 = 52, and HCO3 = 23. Which interpretation would the nurse rely on when planning the patient's care?
- A. Metabolic acidosis.
- B. Metabolic alkalosis.
- C. Respiratory acidosis.
- D. Respiratory alkalosis.
Correct Answer: C
Rationale: The given ABG results indicate a low pH (acidosis), an elevated PaCO2 (respiratory component), and a normal HCO3 (metabolic component). The low pH and increased PaCO2 suggest respiratory acidosis.
The nurse provides education to a patient with thrombocytopenia about precautions to be taken at home. The nurse identifies that further teaching is needed when the patient performs which action?
- A. Drinks 14 glasses of water daily.
- B. Shaves once a day using an electric razor.
- C. Uses an alcohol-based mouthwash twice a day.
- D. Brushes teeth with a soft-bristle toothbrush twice a day.
Correct Answer: C
Rationale: Using alcohol-based mouthwash can irritate oral mucosa and cause bleeding in thrombocytopenia, indicating a need for further teaching.