Nokea
You are making initial shift assessments on your patients. While assessing one patients peripheral IV site, you note edema around the insertion site. How should you document this complication related to IV therapy?
- A. Air emboli
- B. Phlebitis
- C. Infiltration
- D. Fluid overload
Correct Answer: C
Rationale: Correct Answer: C - Infiltration
Rationale:
1. Infiltration occurs when IV fluid leaks into surrounding tissues, causing edema.
2. Documenting infiltration is important for appropriate management.
3. Air emboli, phlebitis, and fluid overload are unrelated to edema around IV site.
Summary of Incorrect Choices:
A. Air emboli: This is a serious condition caused by air entering the bloodstream, not related to edema.
B. Phlebitis: Inflammation of the vein, usually presenting with redness and pain, not edema.
D. Fluid overload: Excess fluid volume in the body, leading to symptoms like shortness of breath, not edema.
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You are working on a burns unit, and one of your acutely ill patients is exhibiting signs and symptoms of third spacing. Based on this change in status, you should expect the patient to exhibit signs and symptoms of what imbalance?
- A. Metabolic alkalosis
- B. Hypermagnesemia
- C. Hypercalcemia
- D. Hypovolemia
Correct Answer: D
Rationale: Rationale: Third spacing occurs when fluid shifts from the intravascular space to interstitial spaces, leading to hypovolemia. This results in decreased circulating blood volume, leading to signs of hypovolemia such as tachycardia, hypotension, and low urine output. Metabolic alkalosis, hypermagnesemia, and hypercalcemia are not directly related to third spacing and are not the expected imbalances in this scenario.
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse?
- A. Redness at the catheter insertion site
- B. Report of headache and stiff neck
- C. Temperature of 100.1 F (37.8 C)
- D. Pain rating of 8 on a scale of 0 to 10
Correct Answer: B
Rationale: The correct answer is B: Report of headache and stiff neck. This finding indicates a potential complication of epidural anesthesia called a post-dural puncture headache, which can lead to serious consequences like meningitis or subdural hematoma. The nurse should act immediately by notifying the healthcare provider for further evaluation and management. Redness at the catheter insertion site (A) may indicate local inflammation but doesn't require immediate intervention. Temperature elevation (C) could be a sign of infection but isn't as urgent as a headache and stiff neck. Pain rating of 8 (D) is important but doesn't indicate an immediate threat to the client's health like a post-dural puncture headache.
A newly graduated nurse is admitting a patient with a long history of emphysema. The new nurses preceptor is
going over the patients past lab reports with the new nurse. The nurse takes note that the patients PaCO2 has been
between 56 and 64 mm Hg for several months. The preceptor asks the new nurse why they will be cautious
administering oxygen. What is the new nurses best response?
- A. The patients calcium will rise dramatically due to pituitary stimulation.
- B. Oxygen will increase the patients intracranial pressure and create confusion.
- C. Oxygen may cause the patient to hyperventilate and become acidotic.
- D. Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia.
Correct Answer: D
Rationale: The correct answer is D: Using oxygen may result in the patient developing carbon dioxide narcosis and hypoxemia. In patients with chronic emphysema, their respiratory drive is often triggered by low oxygen levels rather than high carbon dioxide levels. Administering supplemental oxygen can suppress their respiratory drive, leading to carbon dioxide retention (carbon dioxide narcosis) and worsening hypoxemia. This phenomenon is known as "hypoxic drive."
Choice A is incorrect because administering oxygen does not lead to a dramatic rise in calcium levels due to pituitary stimulation. Choice B is incorrect because administering oxygen does not typically increase intracranial pressure or cause confusion. Choice C is incorrect because administering oxygen does not directly cause hyperventilation and acidosis in this scenario.
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
- A. Ask family members to speak quietly to keep the client calm.
- B. Assess urine color, amount, and specific gravity each day.
- C. Encourage the client to drink at least 1 liter of fluids each shift.
- D. Dangle the client on the bedside before ambulating.
Correct Answer: D
Rationale: The correct answer is D because dangling the client on the bedside before ambulating helps prevent orthostatic hypotension and potential falls. This step allows the nurse to assess the client's tolerance to changes in position and reduces the risk of injury.
A: Asking family members to speak quietly does not directly address the prevention of injury related to dehydration.
B: Assessing urine parameters is important for monitoring hydration status but does not directly prevent injury.
C: Encouraging fluid intake is important for rehydration but does not directly address the risk of injury during ambulation.
A client at risk for mild hypernatremia is being taught by a nurse. Which statement should the nurse include in this client's teaching?
- A. Weigh yourself every morning and every night
- B. Check your radial pulse twice a day
- C. Read food labels to determine sodium content
- D. Bake or grill the meat rather than frying it
Correct Answer: C
Rationale: The correct answer is C. Reading food labels to determine sodium content is important in managing mild hypernatremia. This allows the client to monitor and control their sodium intake, which can help prevent further elevation of sodium levels. Weighing oneself or checking the pulse does not directly address sodium intake. Choosing cooking methods like baking or grilling is more about reducing fat intake, not sodium.