Nokea
Which of the ff. positions is best for a chest drainage system when the patient is being transported by wheelchair?
- A. Hang it on the top of the wheelchair backrest.
- B. Place it on the patient's feet and ask the patient to hold it.
- C. Hang it on the same pole as the patient's IV.
- D. Place it in the patient's lap.
Correct Answer: A
Rationale: The best position for a chest drainage system when the patient is being transported by wheelchair is to hang it on the top of the wheelchair backrest (Option A). This ensures that the chest drainage system remains upright and secure during transportation. Placing it on the patient's feet and asking the patient to hold it (Option B) is not ideal as it can cause discomfort and potentially compromise the drainage system. Hanging it on the same pole as the patient's IV (Option C) may lead to entanglement and interference with the IV line. Placing it in the patient's lap (Option D) is also not recommended as it can be cumbersome and may lead to accidental dislodgement of the chest drainage system. Therefore, hanging it on the top of the wheelchair backrest provides stability and ease of transport for the patient.
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Marichu is admitted to the hospital because of hepatic failure and was prescribed with lactulose (Duphalac). The primary action of this drug is:
- A. prevent constipation
- B. decrease resident intestinal flora
- C. increase intestinal peristalsis
- D. prevent portal hypertension
Correct Answer: B
Rationale: Lactulose (Duphalac) is a synthetic sugar that is not absorbed in the small intestine but is broken down by bacteria in the colon into short-chain fatty acids and low molecular weight organic acids. The primary action of lactulose is to decrease resident intestinal flora. This reduces the production of ammonia in the colon and leads to acidification of the colonic contents. By doing so, lactulose helps in treating hepatic encephalopathy, a condition associated with hepatic failure where ammonia levels are elevated in the body. It works by promoting the excretion of ammonia through the stool, thereby reducing the toxic effects of ammonia on the brain.
A 45-year old female diabetic is displaying signs of irritability and irrational behavior during an office visit. The nurse observes visible tremors in the client's hands. based on the client's history and the nurse's understanding of diabetes mellitus, the nurse interprets these findings to be signs of:
- A. hyperglycemia
- B. hyperglycemic hyperosmolar
- C. diabetic ketoacidosis (DKA) nonketosis (HHNK)
- D. hypoglycemia
Correct Answer: D
Rationale: The signs of irritability, irrational behavior, and visible tremors in the hands observed in the 45-year old female diabetic suggest hypoglycemia. Hypoglycemia occurs when blood sugar levels drop below normal levels, causing the body and brain to receive inadequate fuel. This leads to symptoms like irritability, irrational behavior, and tremors, which are signs of the brain not receiving enough glucose for proper functioning. In diabetic patients, particularly those on medications like insulin or certain oral hypoglycemic agents, hypoglycemia can occur if they take too much medication, skip meals, or engage in excessive physical activity without adjusting their treatment regimen. Immediate treatment for hypoglycemia usually involves consuming a rapid source of sugar, such as glucose tablets, juice, or candy, to quickly raise blood sugar levels back to normal range.
To monitor the severity of a patient's heart failure, which of the ff. assessments is the most appropriate for the nurse to include as a daily assessment in the plan of care?
- A. Weight
- B. Appetite
- C. Calorie count
- D. Abdominal girth
Correct Answer: A
Rationale: Monitoring a patient's weight is a crucial assessment in heart failure management. Sudden weight gain could indicate fluid retention, which is a common sign of worsening heart failure. By regularly monitoring the patient's weight, the nurse can detect early signs of fluid buildup and adjust the treatment plan accordingly. Weight monitoring is a simple yet effective way to assess the severity of heart failure and prevent complications. The other options (B. Appetite, C. Calorie count, D. Abdominal girth) are not as directly related to monitoring heart failure severity as weight measurement.
A client who was diagnosed with type I diabetes mellitus 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?
- A. Cool, moist skin
- B. Arm and leg trembling
- C. Rapid, thready pulse
- D. Slow, shallow respirations
Correct Answer: B
Rationale: A blood glucose level of 470 mg/dl indicates severe hyperglycemia in a client with type I diabetes mellitus. Arm and leg trembling, known as tremors, is a common symptom associated with high blood glucose levels. Tremors are often a result of the body's stress response to the extreme levels of glucose in the blood. Other common symptoms of hyperglycemia include increased thirst, frequent urination, blurred vision, and fatigue. Cool, moist skin, rapid, thready pulse, and slow, shallow respirations are not typically associated with hyperglycemia and are more indicative of other conditions or clinical situations.
Which of the following disorders leads to cyanosis from deoxygenated blood entering the systemic arterial circulation?
- A. Aortic stenosis (AS)
- B. Coarctation of aorta
- C. Patent ductus arteriosus (PDA)
- D. Tetralogy of Fallot
Correct Answer: D
Rationale: Tetralogy of Fallot is a congenital heart defect characterized by four primary abnormalities: pulmonary stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. Due to the pulmonary stenosis, less blood reaches the lungs to be oxygenated, resulting in deoxygenated blood entering the systemic arterial circulation. This leads to cyanosis, which is often referred to as "Tet spells" in these patients. Cyanosis is the bluish discoloration of the skin and mucous membranes caused by the presence of deoxygenated hemoglobin. The other conditions listed do not typically result in deoxygenated blood entering the systemic arterial circulation and causing cyanosis.