Nokea
Which of these signs suggests that a client with the syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?
- A. Tetanic contractions
- B. Weight loss
- C. Neck vein distention
- D. Polyuria
Correct Answer: C
Rationale: The correct answer is C: Neck vein distention. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia, causing fluid overload. This can manifest as neck vein distention due to increased venous pressure. Tetanic contractions (A) and weight loss (B) are not typical complications of SIADH; tetany is more associated with hypocalcemia and weight loss is not a common manifestation. Polyuria (D) is actually the opposite of what is seen in SIADH, which is characterized by water retention and concentrated urine.
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After a Whippie procedure for cancer of the pancreas, a client is to receive the following intravenous (IV) fluids over 24 hours; 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. The nurse calculates that the clients IV fluid intake Tor 24 hours will be:
- A. 3150ml
- B. 3650 ml
- C. 3200 ml
- D. 3750ml
Correct Answer: D
Rationale: The correct answer is D (3750ml) because the client will receive 1000ml D5W + 500ml normal saline + 1500ml D5NS + 50ml antibiotic every 8 hours x 3 times in 24 hours (50ml x 3 = 150ml). Adding these together gives a total of 1000ml + 500ml + 1500ml + 150ml = 3150ml. Therefore, the client's IV fluid intake for 24 hours will be 3150ml.
The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?
- A. Dependent NursingStoreRN
- B. Independent
- C. Interdependent
- D. Physician-initiated
Correct Answer: C
Rationale: The correct answer is C: Interdependent. In this scenario, the nurse performed an intervention for a collaborative problem, which involves working together with other healthcare professionals to address the issue. Interdependent interventions require collaboration and communication among healthcare team members to achieve the best outcomes for the patient.
Choice A (Dependent Nursing) refers to interventions that require an order from a healthcare provider.
Choice B (Independent) involves nursing actions that the nurse can initiate without the need for a healthcare provider's order.
Choice D (Physician-initiated) specifically denotes interventions initiated by a physician without direct involvement from the nurse.
In this case, the nurse's intervention for a collaborative problem aligns with the definition of interdependent intervention, making it the correct choice.
The nurse is preparing to administer a unit of blood to a client’s who’s anemic. After its removal from the refrigerator, the blood should be administered within:
- A. 1 hour
- B. 4 hours
- C. 2 hours
- D. 6 hours
Correct Answer: C
Rationale: The correct answer is C: 2 hours. Blood should be administered within 30 minutes to 4 hours after removal from the refrigerator to prevent bacterial growth and maintain its efficacy. Option C falls within this timeframe, ensuring safety and effectiveness. Option A (1 hour) is too short, while option B (4 hours) and option D (6 hours) exceed the recommended timeframe, increasing the risk of bacterial contamination and compromising the quality of the blood product.
Approximately how much fluid is lost in acute weight loss of .5kg?
- A. 50 ml
- B. 750 ml
- C. 500 ml
- D. 75 ml
Correct Answer: C
Rationale: The correct answer is C: 500 ml. When someone loses 0.5 kg of weight, it is estimated that about 500 ml of fluid has been lost, as 1 kg of body weight is roughly equivalent to 1 liter of fluid. This fluid loss is due to water loss through sweating, breathing, and urine. Choice A (50 ml) is too small of an amount for a significant weight loss. Choice B (750 ml) is too high and would correspond to a larger weight loss. Choice D (75 ml) is also too small to account for a 0.5 kg weight loss.
Mr. Reyea has expressive aphasia. As a part of a long range planning. The nurse should ;
- A. Provide positive feedback when he uses the word correctly
- B. Wait for him to verbally state needs regardless of how long it may take
- C. Suggest that he get help at home because the disability is permanent
- D. Help the family to accept the fact that Mr, Reyes cannot participate in verbal communication Situation - Patricia Zeno is a client with history myasthenia gravis
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Positive reinforcement helps enhance communication skills in individuals with expressive aphasia.
2. Providing positive feedback when Mr. Reyea uses words correctly encourages him to continue trying to communicate.
3. It boosts his confidence and motivation, leading to improved verbal communication over time.
Summary of why other choices are incorrect:
B. Waiting indefinitely for Mr. Reyea to verbally state his needs may lead to frustration and hinder effective communication.
C. Suggesting permanent help at home assumes Mr. Reyea's condition cannot improve, which is not necessarily true for expressive aphasia.
D. Helping the family accept Mr. Reyea's communication challenges does not actively support his communication improvement and may limit his progress.