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Which of the ff nursing interventions should a nurse perform when caring for a client with congestive heart failure who has decreased cardiac output?
- A. Encourage activities that engage the Valsalva maneuver
- B. Encourage the client to perform exercises
- C. Assess apical heart before administering digitalis
- D. Offer small frequent feedings
Correct Answer: C
Rationale: Decreased cardiac output is a serious concern in clients with congestive heart failure. By assessing the apical heart rate before administering digitalis, the nurse can monitor the client's cardiac status and prevent possible complications such as digitalis toxicity. Digitalis is a medication commonly used to improve cardiac output in clients with heart failure, but it can also cause harm if given inappropriately, especially if the client's heart rate is already low. Monitoring the client's apical heart rate before giving digitalis helps ensure that the medication is safely administered and that the client's cardiac status is closely monitored. This intervention is crucial in the care of clients with congestive heart failure to optimize patient safety and outcomes.
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The client is a type II DM patient. The client asks the nurse what is the primary reason a type II diabetic does not usually develop diabetic ketoacidosis?
- A. there is no insulin available for the state of hyperglycemia
- B. the type II diabetic has no protein of fat reserves
- C. there is no sufficient insulin to prevent the breakdown of protein and fatty acid for metabolic needs
- D. there is insufficient serum glucose concentrations
Correct Answer: C
Rationale: The primary reason a type II diabetic does not usually develop diabetic ketoacidosis is that there is no sufficient insulin to prevent the breakdown of protein and fatty acids for metabolic needs. In type II diabetes, the body still produces some insulin, unlike in type I diabetes where there is a complete lack of insulin. However, the insulin that is produced in type II diabetes may not be enough to effectively lower blood sugar levels and prevent the breakdown of protein and fatty acids for energy. This imbalance can lead to high blood sugar levels, known as hyperglycemia, but not to the extent of causing diabetic ketoacidosis, which typically occurs in the absence of sufficient insulin to prevent the breakdown of fats into ketones.
Which of the ff should qualify as an abnormal result in a Romberg test?
- A. Hypotension
- B. Swaying, losing balance, or arm drifting
- C. Sneezing and wheezing
- D. Excessive cerumen in the outer ear
Correct Answer: B
Rationale: During a Romberg test, the individual is asked to stand with feet together, arms at sides, and eyes closed. The tester then observes for swaying, losing balance, or arm drifting, which are signs of a positive Romberg test, indicating a potential issue with proprioception or vestibular function. Hypotension (choice A) refers to low blood pressure and is not directly assessed during a Romberg test. Sneezing and wheezing (choice C) are unrelated symptoms. Excessive cerumen in the outer ear (choice D) does not affect the results of a Romberg test focused on balance and proprioception.
The nurse is instructed to perform preoperative preparation for the management of a client with malignant tumors. Which of the ff is the most important factor of the nursing management plan?
- A. Insertion of an ostomy pouch
- B. Assessing the symptoms of peritonitis
- C. Maintaining the integrity of the urinary
- D. Insertion of a nasogastric tube diversion procedure
Correct Answer: B
Rationale: Peritonitis is a serious and potentially life-threatening condition that can occur as a complication of malignant tumors. It is characterized by inflammation of the lining of the abdomen and can result in severe abdominal pain, tenderness, fever, and other symptoms. Prompt assessment of peritonitis symptoms is crucial for early detection and intervention to prevent further complications and improve patient outcomes. Assessing for peritonitis symptoms should be the priority in the nursing management plan to ensure timely and appropriate care for the client with malignant tumors.
A 3-year-old child from a suburban community presents with vomiting, diarrhea, and blurred vision. Physical examination reveals an afebrile child with pinpoint pupils, salivation, and muscular fasciculations. The child's lawn was treated yesterday for insects. Which of the following tests will establish the correct diagnosis?
- A. Blood-lead level
- B. 24-hour urine mercury level
- C. Plasma cholinesterase level
- D. Urine malathion level
Correct Answer: C
Rationale: The symptoms suggest organophosphate poisoning, which can be confirmed by measuring plasma cholinesterase levels, as organophosphates inhibit this enzyme.
An adult has and IV line in the right forearm infusing D5 ½ NS with 20 mEq of potassium at 75 ml/h. which statement would be a correct report from the RN?
- A. The potassium bag is piggybacked into the dextrose at 75ml/h
- B. The clamp should be closed below the D5 ½ NS bag
- C. Potassium is on the secondary line
- D. 75 ml infuse in one hour
Correct Answer: A
Rationale: The correct report from the RN in this situation would be option A. This report accurately describes the situation by mentioning that the potassium bag is piggybacked into the dextrose at 75 ml/h, stating that the clamp should be closed below the D5 ½ NS bag, and clarifying that potassium is on the secondary line. Additionally, the statement that 75 ml will infuse in one hour is also correct based on the infusion rate provided in the question. Therefore, option A is the most appropriate and accurate report to provide in this scenario.