Nokea
You are the nurse caring for a 77-year-old male patient who has been involved in a motor vehicle accident. You
and your colleague note that the patients labs indicate minimally elevated serum creatinine levels, which your
colleague dismisses. What can this increase in creatinine indicate in older adults?
- A. Substantially reduced renal function
- B. Acute kidney injury
- C. Decreased cardiac output
- D. ) Alterations in ratio of body fluids to muscle mass
Correct Answer: A
Rationale: The correct answer is A: Substantially reduced renal function. In older adults, elevated serum creatinine levels can indicate impaired kidney function, as the kidneys may not filter waste products as efficiently. This can lead to a buildup of creatinine in the blood. Acute kidney injury (Choice B) is a sudden decline in kidney function and would typically present with a more significant increase in creatinine levels. Decreased cardiac output (Choice C) would not directly cause elevated creatinine levels. Alterations in the ratio of body fluids to muscle mass (Choice D) would not be a common cause of elevated creatinine levels in this scenario.
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The nurse is assessing the patient for the presence of a Chvosteks sign. What electrolyte imbalance would a
positive Chvosteks sign indicate?
- A. Hypermagnesemia
- B. Hyponatremia
- C. Hypocalcemia
- D. Hyperkalemia
Correct Answer: C
Rationale: Step 1: Chvostek's sign is a facial muscle spasm induced by tapping the facial nerve in hypocalcemia.
Step 2: Hypocalcemia causes increased neuromuscular excitability, leading to Chvostek's sign.
Step 3: Hyperkalemia (choice D) causes muscle weakness, not muscle spasm.
Step 4: Hyponatremia (choice B) affects osmolarity, not neuromuscular excitability.
Step 5: Hypermagnesemia (choice A) causes muscle weakness, not muscle spasm.
A gerontologic nurse is teaching students about the high incidence and prevalence of dehydration in older adults.
What factors contribute to this phenomenon? Select all that do not apply.
- A. Decreased kidney mass
- B. Decreased renal blood flow
- C. Decreased excretion of potassium
- D. Increased conservation of sodium
Correct Answer: D
Rationale: The correct answer is D: Increased conservation of sodium. Older adults tend to have an increased conservation of sodium, leading to fluid retention and decreased fluid intake, which can contribute to dehydration.
A: Decreased kidney mass is incorrect because it is a factor that can contribute to decreased kidney function but not directly linked to dehydration.
B: Decreased renal blood flow can impact kidney function but is not a direct cause of dehydration in older adults.
C: Decreased excretion of potassium is not a factor that directly contributes to dehydration in older adults.
1.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure?
- A. Lower the extremity below the level of the heart.
- B. Apply warm compresses to the extremity.
- C. Tap the skin lightly and avoid slapping.
- D. Place a washcloth between the skin and tourniquet
Correct Answer: D
Rationale: The correct answer is D: Place a washcloth between the skin and tourniquet. This step helps protect the client's skin by providing a barrier between the tourniquet and the skin, reducing the risk of skin irritation or damage. Lowering the extremity below the heart (A) can increase venous pressure and make it harder to insert the catheter. Warm compresses (B) can dilate blood vessels and increase the risk of bruising. Tapping the skin lightly (C) can irritate the skin and is unnecessary for skin protection.
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.
A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
- A. Assess the airway.
- B. Administer prescribed bronchodilators.
- C. Provide oxygen.
- D. Administer prescribed mucolytics
Correct Answer: A
Rationale: The correct answer is A: Assess the airway. The nurse should prioritize airway assessment as the client's ABGs indicate respiratory acidosis (low pH, high PaCO2). This suggests potential airway obstruction or inadequate ventilation. Ensuring a patent airway is crucial for adequate oxygenation. Administering bronchodilators (B) or mucolytics (D) may help with airway clearance but should come after ensuring a clear airway. Providing oxygen (C) is important, but addressing the underlying respiratory acidosis by first assessing the airway is the priority in this situation to prevent further deterioration.