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Why should the nurse closely monitor older adults when they are receiving IV therapy? Choose all that apply
- A. Because their defense mechanisms are less efficient
- B. Because they are prone to fluid overload
- C. Because they are prone to reduced renal efficiency
- D. Because they have inadequate intake of dietary fiber
Correct Answer: E
Rationale: Older adults should be closely monitored when receiving IV therapy because their defense mechanisms are less efficient (A) as they age, making them more susceptible to infections and complications from invasive procedures like IV therapy. Additionally, older adults are prone to reduced renal efficiency (C), which can affect their ability to excrete excess fluids and electrolytes properly. Monitoring for signs of fluid overload and renal impairment is crucial in this population to prevent adverse outcomes related to IV therapy.
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Where in the health history should the nurse describe all details related to the chief complaint?
- A. Past history
- B. Chief complaint
- C. Present illness
- D. Review of systems
Correct Answer: C
Rationale: The nurse should describe all details related to the chief complaint under the "Present illness" section of the health history. This section focuses specifically on the patient's current health problem, including the onset, duration, severity, aggravating or alleviating factors, and associated symptoms. It provides a comprehensive understanding of the chief complaint and helps guide further assessment and treatment interventions. The "Chief complaint" section typically contains a concise statement from the patient regarding the main reason for seeking healthcare.
A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse in charge anticipates that the doctor will order which laboratory test?
- A. Total iron-binding capacity
- B. Hemoglobin
- C. Total protein
- D. Serum transferrin
Correct Answer: C
Rationale: Total protein is a laboratory test that is commonly ordered to assess the nutritional status of an individual. In the case of a child with poor nutritional status and weight loss, assessing the total protein levels can help in diagnosing a negative nitrogen balance. Total protein levels may decrease in individuals with inadequate protein intake, malnutrition, or negative nitrogen balance. Monitoring total protein levels can provide valuable information about the child's nutritional status and help guide further interventions to improve their overall health and well-being.
The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take?
- A. The nurse should insert a padded tongue blade in the patient's mouth to prevent the child from swallowing or choking on his tongue.
- B. The nurse should help the mother restrain the child to prevent him from injuring himself.
- C. The nurse should call the operator to page for seizure assistance.
- D. The nurse should clear the area and position the client safely.
Correct Answer: D
Rationale: In this situation, the nurse's priority is to provide a safe environment for the patient during the seizure. Inserting a padded tongue blade (Option A) is not recommended as it can cause more harm than good, such as dental injury. Restraint of the patient (Option B) during a seizure is also not recommended as it can lead to injury. Calling the operator to page for seizure assistance (Option C) may delay immediate intervention. The best course of action is for the nurse to clear the area of any objects that may injure the patient during the seizure and position the client safely. This will help prevent injury and ensure the patient's safety until the seizure subsides.
The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure (HF). Which is a beneficial effect of administering digoxin (Lanoxin)?
- A. It decreases edema.
- B. It decreases cardiac output.
- C. It increases heart size.
- D. It increases venous pressure.
Correct Answer: A
Rationale: Digoxin is a medication commonly used in the treatment of heart failure (HF) because of its positive inotropic effect, which means it strengthens the heart muscle. While digoxin does not directly decrease edema, its ability to increase the strength of the heart muscle allows the heart to pump more effectively. When the heart is pumping blood more efficiently, it can help reduce fluid accumulation in the body, including edema.
An infant with bladder exstrophy has had a continent urinary reservoir placed. Which discharge instruction should be included?
- A. Allow your child to sleep on the abdomen for comfort.
- B. Avoid contact with latex-containing surfaces (e.g., playgrounds with rubber) to prevent allergic reactions.
- C. Encourage a varied diet to prevent allergies.
- D. Provide brightly colored objects to stimulate development.
Correct Answer: B
Rationale: Children with urologic malformations are prone to latex allergies; parents should be advised to avoid latex exposure.