Nokea
Which of the ff dietary recommendations should a nurse give to a client taking diuretics?
- A. Include potassium rich foods
- B. Avoid fruit and fruit juices
- C. Include protein rich foods
- D. Avoid dairy products
Correct Answer: A
Rationale: The correct answer is A: Include potassium-rich foods. Diuretics can cause potassium loss, leading to hypokalemia. Including potassium-rich foods helps prevent this deficiency. Choice B is incorrect because fruits and fruit juices are often good sources of potassium. Choice C is incorrect as protein-rich foods do not specifically address potassium needs. Choice D is incorrect as dairy products are also good sources of potassium. Therefore, recommending potassium-rich foods is essential to prevent hypokalemia in clients taking diuretics.
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Mr. Chua has developed liver cirrhosis. Nurse Bea expects alteration in which laboratory values?
- A. carbon dioxide level
- B. prothrombin time
- C. gastric pH
- D. white blood cell count
Correct Answer: B
Rationale: The correct answer is B: prothrombin time. In liver cirrhosis, the liver's ability to produce clotting factors is impaired, leading to prolonged prothrombin time. This indicates an increased risk of bleeding. Choice A is incorrect as carbon dioxide levels are not typically affected by liver cirrhosis. Choice C, gastric pH, is unrelated to liver function. Choice D, white blood cell count, is not directly affected by liver cirrhosis. Therefore, the alteration in prothrombin time is the most relevant laboratory value to monitor in this case.
Deaths have occurred when potassium chloride has been used incorrectly to flush a lock or central venous catheter. Which of the ff precautions should a nurse take to minimize this risk?
- A. Use a dilute form of potassium chloride before flushing locks
- B. Warm the KCL before flushing locks
- C. Read labels carefully on vials containing flush solutions for locks
- D. Replace the existing locks with new ones to avoid flushing
Correct Answer: C
Rationale: Step 1: Reading labels carefully on vials containing flush solutions for locks is crucial to ensure the correct solution is being used.
Step 2: Potassium chloride should not be used to flush locks as it can be fatal if administered incorrectly.
Step 3: By carefully reading labels, the nurse can verify that the correct solution is being used, thus minimizing the risk of using potassium chloride.
Summary:
- Choice A is incorrect as using a dilute form of potassium chloride does not address the issue of incorrect administration.
- Choice B is incorrect as warming the solution does not prevent the risk associated with using potassium chloride.
- Choice D is incorrect as replacing locks does not address the root cause of the issue, which is improper administration.
The multilumen pulmonary artery catheter allows the nurse to measure hemodynamic pressures at different points in the heart. When the tip enters the small branches of the pulmonary artery, the nurse can assess all of the following except:
- A. Central venous pressure (CVP)
- B. Pulmonary artery capillary pressure (PACP)
- C. Pulmonary artery obstructive pressure (PACP)
- D. Pulmonary artery wedge pressure (PAWP)
Correct Answer: C
Rationale: The correct answer is C: Pulmonary artery obstructive pressure (PACP). The multilumen pulmonary artery catheter measures hemodynamic pressures in the heart. When the catheter tip enters small branches of the pulmonary artery, it can assess Central Venous Pressure (A), Pulmonary Artery Capillary Pressure (B), and Pulmonary Artery Wedge Pressure (D). Pulmonary artery obstructive pressure is not a standard hemodynamic measurement and is not assessed using this catheter. It is crucial to differentiate between the various pressures measured to accurately assess the patient's cardiac status.
Which of the ff is the effect of a decrease in the number of lymphocytes with age?
- A. Decreased resistance to infection
- B. Cognitive problems
- C. Urinary incontinence
- D. Decrease in various blood components
Correct Answer: A
Rationale: The correct answer is A: Decreased resistance to infection. Lymphocytes are a crucial part of the immune system, responsible for fighting off infections. A decrease in the number of lymphocytes with age leads to a weakened immune response, making individuals more susceptible to infections.
- Choice B: Cognitive problems, is not directly related to lymphocyte levels.
- Choice C: Urinary incontinence, is not a typical effect of decreased lymphocytes.
- Choice D: Decrease in various blood components, is too broad and not specific to the role of lymphocytes in immunity.
Which nursing interventions can help prevent falls in a patient with Parkinson’s disease? Choose all answers that are correct. i.Keep the patient’s call light within reach ii.Apply a soft vest restraint when the patient is in bed iii.Avoid use of throw rugs iv.Maintain the patient’s bed in a low position v.Encourage the patient to be independent for as long as possible vi.Provide a cane or walker for ambulation
- A. 1, 4, 2005
- B. 1, 3, 4, 6
- C. 2, 3, 2006
- D. 2, 4, 5, 6
Correct Answer: A
Rationale: The correct answers are i. Keep the patient’s call light within reach, iii. Avoid use of throw rugs, and iv. Maintain the patient’s bed in a low position.
1. Keeping the call light within reach ensures the patient can easily call for assistance, reducing the risk of falls.
2. Avoiding throw rugs prevents tripping hazards that can lead to falls.
3. Maintaining the bed in a low position reduces the risk of injury if the patient falls out of bed.
The incorrect choices:
- Choice B includes answer 3 (Avoid use of throw rugs), which is correct, but also includes answer 6 (Provide a cane or walker for ambulation), which is not specific to fall prevention.
- Choice C includes answer 2 (Apply a soft vest restraint when the patient is in bed), which can increase the risk of falls due to restricted movement.
- Choice D includes answers that are not directly related to fall prevention, such as 2 (Apply a soft vest