Nokea
Which of the following symptoms most likely indicates that an infusion is infiltrated?
- A. Redness at the site
- B. Pain at the site
- C. Puffiness at the site
- D. Exudate at the site
Correct Answer: C
Rationale: Puffiness at the site is the symptom that most likely indicates that an infusion is infiltrated. Infiltration occurs when the IV fluid leaks into the surrounding tissues instead of entering the vein. This can lead to swelling and puffiness at the site as the fluid accumulates in the tissue. Redness, pain, and exudate at the site are also common signs of infiltration, but puffiness specifically points towards the fluid accumulating outside the vein. If infiltration is suspected, it is important to stop the infusion, remove the IV catheter, and apply appropriate treatment based on the severity of the infiltration.
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Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?
- A. massive ascites formation
- B. fluid volume excess
- C. increased serum ammonia levels
- D. altered clotting mechanism
Correct Answer: C
Rationale: Hepatic encephalopathy is a neuropsychiatric complication of advanced liver disease, such as cirrhosis, where the liver's ability to metabolize ammonia is impaired. As a result, there is an increase in serum ammonia levels, leading to alterations in brain function and neurotransmission. Symptoms such as confusion, restlessness, and asterixis (flapping tremor) are characteristic of hepatic encephalopathy caused by increased ammonia levels affecting the brain. Therefore, altered thought processes in Mrs. Silang are primarily related to the increased serum ammonia levels rather than other factors like massive ascites formation, fluid volume excess, or altered clotting mechanism.
A patient's serum sodium is within normal range. The nurse estimates that serum osmolality should be:
- A. Less than 136mOsm/kg
- B. Greater than 408mOsm/kg
- C. 280 to 295mOsm/kg
- D. 350 to 544mOsm/kg
Correct Answer: C
Rationale: Normal serum osmolality typically ranges between 280 to 295mOsm/kg. Serum osmolality reflects the concentration of solute particles in the blood, including sodium, glucose, and blood urea nitrogen. Sodium is a major determinant of serum osmolality, but it is not the only factor. In this case, since the patient's serum sodium is within the normal range, the nurse can reasonably estimate that the serum osmolality would fall within the normal range of 280 to 295mOsm/kg. Options A, B, and D are outside the typical range for serum osmolality in a healthy individual.
According to developmental theories, which event is essential to toddler development?
- A. Learning to feed oneself.
- B. Developing friendships.
- C. Learning to walk.
- D. Being potty-trained.
Correct Answer: D
Rationale: The mastery of toilet training is considered a key developmental milestone during the toddler period.
The pediatric nurse prepares a patient, who is newly paralyzed, for discharge. The patient will require home care, ancillary therapies, complex medication regimens, and would benefit from a peer support group. To ensure adequate preparation for discharge and transition to home life, the nurse will:
- A. ask the social worker or case manager to organize a care conference.
- B. assess the family for transportation needs.
- C. call the medical supply company to ensure delivery of home care equipment.
- D. contact the patient's school to ensure its readiness to accommodate the patient.
Correct Answer: A
Rationale: Organizing a care conference ensures all aspects of the patient's care are addressed and coordinated effectively.
All the following are true about infant sleep between 2-6 months EXCEPT
- A. total sleep hours are about 14-16 hr/24 hr
- B. sleeps about 9-10 hr concentrated at night
- C. sleeps 2 naps/day
- D. the sleep cycle time is similar to that of adults
Correct Answer: D
Rationale: Infant sleep cycles differ significantly from adult patterns.