Question

Test I
1. A patient was rushed in the hospital following a bloody diarrhea several times. He was noted with a blood pressure of 78/40mmHg, respiration of 30, shallow and rapid, cold clammy skin, lethargic and is pale. Which of the following nursing intervention should the nurse anticipate? Select all that apply. *
4 points
A. IV fluid of 0.9% NSS using a gauge 22 needle inserted at the metacarpal veins.
B. Oxygen support at 5 liters per minute of oxygen using non-rebreather face mask.
C. IV line of PLRS given as IV bolus using a gauge 18 needle and another line of 0.9% NSS regulated at 140cc per hour.
D. STAT blood typing and securing type-specific blood product.
E. Elevating the head of the head at 90 degrees
F. Coordinating with the OR team for possible surgery.
2. A patient has been on steroid therapy for a longtime. She came in the hospital complaining of edema on both feet. Upon assessment, the nurse noted bilateral edema, pitting 2+, with coarse crackles on both lung fields and elevated blood pressure of 150/97mmHg. Which of the following nursing diagnosis is appropriate for the client?
A. Fluid volume deficit
B. Fluid volume excess
C. Risk for infection
D. Deficient knowledge
3. You are a nurse caring for a client with fluid volume excess secondary to SIADH. The physician orders: weigh patient daily. What are following are the rules in implementing the order to weigh patient daily.
4. The nurse was caring for a client with hyperkalemia secondary to acute renal failure. The serum K+ was noted at 6.8mmol/L. Which of the following interventions should the nurse anticipate implementing? Select all that apply
A. Attaching the patient to cardiac telemetry
B. Infusing normal balance maintenance IV fluids
C. Preparing to administer 10 units of regular insulin in 50ml of 50% dextrose in water solution to be given IVbolus
D. Preparing calcium gluconate slow IV push
E. Administering spironolactone
F. Preparing the patient for possible STAT hemodialysis
5. The patient has undergone total thyroidectomy 16 hours ago. While you are assessing her blood pressure, you noticed a slight twitching of the arm while inflating the cuff of the sphygmomanometer. Which of the following should the nurse suspect?
A. Hypernatremia
B. Hyponatremia
C. Hypocalcemia
D. Hypercalcemia
6. A patient is diagnosed with pre-eclampsia and is maintained on magnesium sulfate infusion at 1 gram per hour. At around 8am, the urine drainage in her IFC is at 50cc. At 9am, the drainage was at 40cc and at 10am at drainage is at 38cc. Which of the following action should the nurse do? Select all that apply.
A. Stop the magnesium sulfate infusion
B. Report the finding to the physician
C. Continue the magnesium infusion, however, regulate it at 0.5 grams per hour.
D. Encourage oral fluid intake
E. Assess the respiratory rate and DTR of the client
7. A newly-hired nurse has been assigned in your floor. She is about give potassium IV to a client who was diagnosed with severe gastroenteritis with a serum potassium of 2.7mmol/L. You are observing her as she administer the drug. You noticed her that she connected the syringe in the needleless port of the 3-way stopcock in the main IV line. Which of the following is the appropriate intervention.
A. Interrupt the newly-hired nurse, instruct him to get another IV set for you and remove the syringe from the 3-way stopcock
B. Let the newly-hired nurse give the potassium direct IV telling her to give it via very slow IV push
C. Yell at the nurse and tell her she's committing a mistake.
D. Let the nurse give the potassium direct IV but report the incident to the supervisor.
8. The nurse was caring for a client with on total parenteral nutrition. He noted that the client has dry mouth, poor skin turgor with elevated serum sodium. Which of the following reasons may cause a person to be hypernatremic while on TPN? Select all that apply.
A. TPN does not contain enough water to meet the daily fluid requirement of the client.
B. Clients on tube or parenteral feeding usually are not given enough water.
C. TPN solutions are very high in sodium.
D. The patient in TPN is taking sodium supplements and diuretics

Answer 1

1) Correct answer is (C): To correct dehydration by appropriate fluid management. The best IV Fluid solutions for rehydration are isotonic solutions:Ringers lactate solution and Norma saline solution (0.9NaCl)

2) Correct answer is (B) Fluid volume excess: One of the side effects of steroid therapy is fluid retention,causing swelling in the lower legs.

3) The patient with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) nursing intervention rationale on daily weight.

Patient may be on fluid restrictions to help balance intake and output.Monitor for retention through calculated intake and output and with daily weights at the same time on the same scale each day.

4) Correct answers are A,B,C,D, and F

A: Attaching the patient to cardiac telemetry.In hyperkalemia there will be cardiac dysfunction exhibits with ECG changes and cardiac dysthymia.

B) Infusing normal balance maintenance IV Fluid for easy vascular access in emergency situation.

C: Intravenous administration of glucose and insulin,which promotes movement of potassium from the extra cellular space back into the cells

D) Preparing calcium gluconate slow IV push,it antagonizes the toxic effects of hyperkalemia at the cell membrane.

F) Possible STAT hemodialysis is the definitive treatment of hyperkalemia.Intravenous calcium is used to stabilize the mayocardium,intravenous insulin and nebulized albuterol lower serum Potassium acutely,by shifting it into the cells.

E) Hyperkalemia is an adverse effect of spironolactone so it is contra indicated.