Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? a) Lactated Ringer’s solution Replacement fluids may include isotonic electrolyte solutions and blood component therapy.

Which of the following solutions should the nurse anticipate for
fluid replacement in the male patient?
a) Lactated Ringer’s solution
Replacement fluids may include isotonic electrolyte solutions and blood
component therapy.
b) Type O negative blood
O negative blood is prepared for emergency use in women of
childbearing age.
c) Dextrose 5% in water
Dextrose 5% in water should not be used to replace fluids in
hypovolemic patients.
d) Hypertonic saline
Hypertonic saline is used only to treat severe symptomatic
hyponatremia and should be used only in intensive care units.
by

1 Answer

Answer :

a) Lactated Ringer’s solution
Replacement fluids may include isotonic electrolyte solutions and blood
component therapy.
by

Related questions

Which of the following solutions is hypotonic? a) 0.45% NaCl. Half-strength saline is hypotonic b) Lactated Ringer’s solution. Lactated Ringer’s is isotonic. c) 0.9% NaCl. Normal saline (0.9% NaCl) is isotonic. d) 5% NaCl. A solution that is 5% NaCl is hypertonic.

Description : Which of the following solutions is hypotonic? a) 0.45% NaCl. Half-strength saline is hypotonic b) Lactated Ringer’s solution. Lactated Ringer’s is isotonic. c) 0.9% NaCl. Normal saline (0.9% NaCl) is isotonic. d) 5% NaCl. A solution that is 5% NaCl is hypertonic.

Last Answer : a) 0.45% NaCl. Half-strength saline is hypotonic

Which of the following colloids is expensive but rapidly expands plasma volume? a) Albumin Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure. b) Dextran Dextran is a colloid, synthetic plasma expander that interferes with platelet aggregation and is not recommended for hemorrhagic shock. c) Lactated Ringers Lactated ringers is a crystalloid, not a colloid. d) Hypertonic Saline Hypertonic saline is a crystalloid, not a colloid.

Description : Which of the following colloids is expensive but rapidly expands plasma volume? a) Albumin Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure ... , not a colloid. d) Hypertonic Saline Hypertonic saline is a crystalloid, not a colloid.

Last Answer : a) Albumin Albumin is a colloid that requires human donors, is limited in supply, and can cause congestive heart failure.

Which of the following statements are true of elevated–anion gap metabolic acidosis? A. Hypoperfusion from the shock state rarely produces an elevated anion gap. B. Retention of sulfuric and phosphoric acids may lead to this form of acidosis. C. Copious diarrhea does not produce this condition. D. Rapid volume expansion may produce this form of acidosis. E. Use of lactated Ringer's solution is inappropriate in the treatment of lactic acidosis.

Description : Which of the following statements are true of elevated-anion gap metabolic acidosis? A. Hypoperfusion from the shock state rarely produces an elevated anion gap. B. Retention of sulfuric and phosphoric ... E. Use of lactated Ringer's solution is inappropriate in the treatment of lactic acidosis.

Last Answer : Answer: BC DISCUSSION: An elevated anion gap may be produced by lactic acidosis from shock or by retention of inorganic acids from uremia. Lactated Ringer's solution rapidly corrects the ... . Bicarbonate loss from diarrhea and dilutional acidosis are non-anion gap types of metabolic acidosis

41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Description : 41. For a client complaining of mild musculoskeletal pain, the nurse will anticipate that the treatment for this client’s level of discomfort will include which of the following?

Last Answer : B. Acetaminophen

When the post-cardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects which of the following electrolyte imbalances? a) Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, cardiac arrest.

Description : When the post-cardiac surgical patient demonstrates vasodilation, hypotension, hyporeflexia, slow gastrointestinal motility (hypoactive bowel sounds), lethargy, and respiratory depression, the nurse suspects ... and QT intervals, broad flat T waves), disorientation, depression, and hypotension.

Last Answer : a) Hypermagnesemia Untreated hypomagnesemia may result in coma, apnea, cardiac arrest.

Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed. b) Minimal urine output of 50 milliliters per hour Minimal urine output may be less than 50 mL/hr. c) Minimal urine output of 10 milliliters per hour Minimal urine output must exceed 10 mL/hr. d) Minimal intake of 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Description : Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are ... 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Last Answer : a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.

In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Description : In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result ... a chair. The patient should be taught to avoid bending forward when seated in a chair.

Last Answer : a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Description : The patient with Herpes Simplex Virus (HSV) encephalitis is receiving acyclovir (Zovirax). The nurse monitors blood chemistry test results and urinary output for a) renal complications related to ... output will alert the nurse to the presence of renal complications related to acyclovir therapy.

Last Answer : a) renal complications related to acyclovir therapy. Monitoring of blood chemistry test results and urinary output will alert the nurse to the presence of renal complications related to acyclovir therapy.

The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could become activated with exposure to strong light, such as sunlight or bright lights. Ordinary indoor light is not a problem. The patient should be counseled to wear protective clothing, such as long-sleeved shirts, sunglasses, and wide-brimmed hats, if the patient has to go outdoors during daylight hours in the first five days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Description : The nurse advises the patient undergoing photodynamic therapy (PDT) for macular degeneration to avoid exposure to direct sunlight or bright lights for a) the first five days after the procedure. ... should avoid exposure to direct sunlight or bright lights for the first five days post-treatment.

Last Answer : a) the first five days after the procedure. Photodynamic therapy includes the use of verteporfin, a light-activated dye. The dye within the blood vessels near the surface of the skin could ... days post-treatment. Inadvertent sunlight exposure can lead to severe blistering of the skin and sunburn.

Pre-operatively, the nurse identified the nursing dagnosis, “Knowledge Deficit: Post-operative communication strategies”. Which of the following is a relevant nursing intervention? A. Clarify information on purpose, anticipate benefits and consequences of total laryngectomy B. Explain that total laryngectomy results in loss of ability to verbally communicate C. Arrange a visit to a post-laryngectomy client who effectively uses an alternative form of verbal communication D. Illustrate means of communicating post- operatively

Description : Pre-operatively, the nurse identified the nursing dagnosis, Knowledge Deficit: Post-operative communication strategies . Which of the following is a relevant nursing intervention? A. ... uses an alternative form of verbal communication D. Illustrate means of communicating post- operatively

Last Answer : D. Illustrate means of communicating post- operatively

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. b) Normal glomerular filtration Indices of normal glomerular filtration are output of 25 ml or greater per hour and specific gravity between 1.010 and 1.025. c) Overhydration Overhydration is manifested by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

The nurse assesses the dressing of a patient with a basal skull fracture and sees the halo sign - a blood stain surrounded by a yellowish stain. The nurse knows that this sign a) is highly suggestive of a cerebrospinal fluid (CSF) leak. The halo sign - a blood stain surrounded by a yellowish stain is highly suggestive of a cerebrospinal fluid (CSF) leak.

Description : The nurse assesses the dressing of a patient with a basal skull fracture and sees the halo sign - a blood stain surrounded by a yellowish stain. The nurse knows that this sign a) is highly ... following a basal skull fracture. The halo sign is highly suggestive of a cerebrospinal fluid (CSF) leak.

Last Answer : a) is highly suggestive of a cerebrospinal fluid (CSF) leak. The halo sign - a blood stain surrounded by a yellowish stain is highly suggestive of a cerebrospinal fluid (CSF) leak.

What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen tanks) that contains metal or metal parts enters the room where the MRI is located. The magnetic field generated by the unit is so strong that any metal-containing items will be strongly attracted and can literally be pulled away with such great force that they can fly like projectiles towards the magnet.

Description : What safety actions does the nurse need to take for a patient on oxygen therapy who is undergoing magnetic resonance imaging (MRI)? a) Ensure that no patient care equipment containing metal enters the ... oxygen tanks) that contains metal or metal parts enters the room where the MRI is located.

Last Answer : a) Ensure that no patient care equipment containing metal enters the room where the MRI is located. For patient safety the nurse must make sure no patient care equipment (e.g., portable oxygen ... literally be pulled away with such great force that they can fly like projectiles towards the magnet.

When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Description : When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement ... Pancrease. Commercially available enzymatic debriding agents include Accuzyme, Clooagenase, Granulex, and Zymase.

Last Answer : a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

When caring for a patient with an uncomplicated, mild urinary tract infection (UTI), the nurse knows that recent studies have shown which of the following drugs to be a good choice for shortcourse (e.g. 3-day) therapy? a) Levofloxacin (Levaquin) Levofloxacin, a floroquinolone, is a good choice for short-course therapy of uncomplicated, mild to moderate UTI. Clinical trial data show high patient compliance with the 3-day regimen (95.6%) and a high eradication rate for all pathogens (96.4%).

Description : When caring for a patient with an uncomplicated, mild urinary tract infection (UTI), the nurse knows that recent studies have shown which of the following drugs to be a good choice for ... to be significantly more effective than TMP-SMX in community-based patients and in nursing home residents.

Last Answer : a) Levofloxacin (Levaquin) Levofloxacin, a floroquinolone, is a good choice for short-course therapy of uncomplicated, mild to moderate UTI. Clinical trial data show high patient compliance with the 3-day regimen (95.6%) and a high eradication rate for all pathogens (96.4%).

Which of the following is true of loss of gastrointestinal secretions? A. Gastric losses are best replaced with a balanced salt solution. B. Potassium supplementation is unnecessary in replacement of gastric secretions. C. Bicarbonate wasting is an unusual complication of a high-volume pancreatic fistula. D. Balanced salt solution is a reasonable replacement fluid for a small bowel fistula. E. A patient with persistent vomiting usually requires hyperchloremic replacement fluids.

Description : Which of the following is true of loss of gastrointestinal secretions? A. Gastric losses are best replaced with a balanced salt solution. B. Potassium supplementation is unnecessary in ... bowel fistula. E. A patient with persistent vomiting usually requires hyperchloremic replacement fluids.

Last Answer : Answer: DE DISCUSSION: Gastric secretions are relatively high in chloride and potassium. Other than an isolated pancreatic fistula, gastrointestinal tract losses below the pylorus ... Although potassium concentrations are low, copious losses require potassium supplementation to prevent hypokalemia

The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

Description : The nurse teaches the female patient who is premenopausal to perform breast self-examination (BSE) a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed ... retention before their menstrual period, BSE is best performed when the time for menses is taken into account.

Last Answer : a) on day 5 to day 7, counting the first day of menses as day 1. BSE is best performed after menses, when less fluid is retained.

The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi-mushy. With a descending colostomy, the feces are semi-mushy. c) mushy. With a transverse colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Description : The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi- ... colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Last Answer : a) solid. With a sigmoid colostomy, the feces are solid.

The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

Description : The nurse assesses subtle personality changes, restlessness, irritability, and confusion in a patient who has sustained a fracture. The nurse suspects a) fat embolism syndrome. Cerebral disturbances in ... severe, burning pain, local edema, hyperesthesia, muscle spasms, and vasomotor skin changes.

Last Answer : a) fat embolism syndrome. Cerebral disturbances in the patient with fat embolism syndrome include subtle personality changes, restlessness, irritability, and confusion.

The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise regimen, increasing dietary calcium and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Description : The nurse teaches the patient with a high risk for osteoporosis about risk-lowering strategies including which of the following statements? a) Walk or perform weight-bearing exercises out ... alcohol and caffeine consumption in moderation, and performing a regular weight-bearing exercise regimen.

Last Answer : a) Walk or perform weight-bearing exercises out of doors. Risk-lowering strategies for osteoporosis include walking or exercising out of doors, performing a regular weight-bearing exercise ... and vitamin D intake, smoking cessation, and consuming alcohol and caffeine consumption in moderation.

Which of the following statements reflects the nursing management of the patient with West Nile Virus infection? There is no treatment for West Nile Virus infection. Patients are supported by fluid replacement, airway management, and standard nursing care support during the time that the patient has meningitis symptoms. a) The incubation period is three to five days. The incubation period (from mosquito bite until onset of symptoms) is between 5–15 days.

Description : Which of the following statements reflects the nursing management of the patient with West Nile Virus infection? There is no treatment for West Nile Virus infection. Patients are supported by fluid replacement ... the virus to animals and humans. There is no human-to-human transmission of virus.

Last Answer : a) The incubation period is three to five days. The incubation period (from mosquito bite until onset of symptoms) is between 5–15 days.

Which of the following factors are associated with increased fluid requirements in the management of patients with burn injury? a) Inhalation injuries Factors associated with increased fluid requirements include inhalation injuries, delayed resuscitation, scald burn injuries, high-voltage electrical injuries, hyperglycemia, alcohol intoxification and chronic diuretic therapy.

Description : Which of the following factors are associated with increased fluid requirements in the management of patients with burn injury? a) Inhalation injuries Factors associated with increased fluid ... fluid requirements. d) Hypoglycemia Hypoglycemia is not associated with increased fluid requirements.

Last Answer : a) Inhalation injuries Factors associated with increased fluid requirements include inhalation injuries, delayed resuscitation, scald burn injuries, high-voltage electrical injuries, hyperglycemia, alcohol intoxification and chronic diuretic therapy.

A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B may cause fever, chills and body aches. The administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to the administration of amphotericin B may prevent these side effects.

Description : A patient with fungal encephalitis receiving amphotericin B complaints of fever, chills, and body aches. The nurse knows that these symptoms a) may be controlled by the administration of ... and cerebral spinal fluid (CSF) cultures. Blood and CSF cultures help diagnosis fungal encephalitis.

Last Answer : a) may be controlled by the administration of diphenhydramine (Benedryl) and acetaminophen (Tylenol) approximately 30 minutes prior to administration of the amphotericin. Administration of amphotericin B ... 30 minutes prior to the administration of amphotericin B may prevent these side effects.

When the nurse reviews the physician’s progress notes for the patient who has sustained a head injury and sees that the physician observed Battle’s sign when the patient was in the Emergency Department, the nurse knows that the physician observed a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

Description : The nurse notes that the patient demonstrates generalized pallor and recognizes that this finding may be indicative of a) anemia. In the light-skinned individual, generalized pallor is a ... . d) local arterial insufficiency. Local arterial insufficiency is characterized by marked localized pallor.

Last Answer : a) anemia. In the light-skinned individual, generalized pallor is a manifestation of anemia. In brown- and black-skinned individuals, anemia is demonstrated as a dull skin appearance.

When the nurse observes diffuse swelling involving the deeper skin layers in the patient who has experienced an allergic reaction, the nurse records the finding as a) angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit.

Description : When the nurse observes diffuse swelling involving the deeper skin layers in the patient who has experienced an allergic reaction, the nurse records the finding as a) angioneurotic edema. ... the result of increased interstitial fluid and associated with disorders such as congestive heart failure.

Last Answer : a) angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit.

When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Description : When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) ... urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.

Last Answer : a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief. b) vomiting. Vomiting is uncommon in the patient with duodenal ulcer. c) hemorrhage. Hemorrhage is less likely in the patient with duodenal ulcer than the patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Regarding oral cancer, the nurse provides health teaching to inform the patient that a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.

Description : Regarding oral cancer, the nurse provides health teaching to inform the patient that a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of ... crater-like. A typical lesion in oral cancer is a painless hardened ulcer with raised edges.

Last Answer : a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.

When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for redness and palpated for hardening. b) drainage. Drainage at the site does not indicate a reaction to the tubercle bacillus. c) tissue sloughing. Sloughing of tissue at the site of injection does not indicate a reaction to the tubercle bacillus. d) bruising. Bruising of tissue at the site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Description : When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for ... site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Last Answer : a) redness and induration. The site is inspected for redness and palpated for hardening.

When the patient who has undergone laryngectomy suffers wound breakdown, the nurse monitors him very carefully because he is identified as being at high risk for a) carotid artery hemorrhage. The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly. b) pulmonary embolism. Pulmonary embolism is associated with immobility. c) dehydration. Dehydration may lead to poor wound healing and breakdown. d) pneumonia. Pneumonia is a risk for any postoperative patient.

Description : When the patient who has undergone laryngectomy suffers wound breakdown, the nurse monitors him very carefully because he is identified as being at high risk for a) carotid artery hemorrhage. The ... poor wound healing and breakdown. d) pneumonia. Pneumonia is a risk for any postoperative patient.

Last Answer : a) carotid artery hemorrhage. The carotid artery lies close to the stoma and may rupture from erosion if the wound does not heal properly.

When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening. b) urgent. Urgent surgery means that the patient requires prompt attention within 24-30 hours. c) required. Required surgery means that the patient needs to have surgery, and it should be planned within a few weeks or months. d) elective. Elective surgery means that there is an indication for surgery, but failure to have surgery will not be catastrophic.

Description : When the indication for surgery is without delay, the nurse recognizes that the surgery will be classified as a) emergency. Emergency surgery means that the patient requires immediate attention and the ... there is an indication for surgery, but failure to have surgery will not be catastrophic.

Last Answer : a) emergency. Emergency surgery means that the patient requires immediate attention and the disorder may be life-threatening.

Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b) tolerance to opioids is uncommon. Tolerance to opioids is common. c) addiction to opioids commonly develops. Addiction to opioids is rare. d) the nurse must be primarily concerned about development of addiction by the patient in pain. Addiction is rare and should never be the primary concern for a patient in pain.

Description : Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b ... pain. Addiction is rare and should never be the primary concern for a patient in pain.

Last Answer : a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction.

A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken together with warfarin a) can greatly increase the international normalization ratio (INR) and therefore increase the risk of bleeding. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

Description : A patient who has had a previous stroke and is taking warfarin tells the nurse that he started taking garlic to help reduce his blood pressure. The nurse knows that garlic when taken ... headaches. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

Last Answer : a) can greatly increase the international normalization ratio (INR) and therefore increase the risk of bleeding. Garlic and warfarin taken together can greatly increase the INR, increasing the risk of bleeding.

When the patient’s eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

Description : When the patient's eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell ... d) normal. Eosinophils normally make up 1-3% of the total number of white blood cells.

Last Answer : a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

Description : When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test ... When antibodies to the AIDS virus are detected in the blood, the test is interpreted as positive.

Last Answer : a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

The nurse teaches the patient about diabetes including which of the following statements? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

Description : The nurse teaches the patient about diabetes including which of the following statements? a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood ... be able to resume previous methods for control of diabetes when the stress is resolved.

Last Answer : a) Elevated blood glucose levels contribute to complications of diabetes, such as diminished vision. When blood glucose levels are well controlled, the potential for complications of diabetes is reduced.

The nurse places the patient after liver biopsy in which of the following positions? a) On the right side In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded.

Description : The nurse places the patient after liver biopsy in which of the following positions? a) On the right side In this position, the liver capsule at the site of penetration is compressed against the chest ... . d) High Fowler's High Fowler's position is not indicated for the patient after liver biopsy.

Last Answer : a) On the right side In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded.

The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is an indicator of shock. c) Warm, dry skin Skin is generally cool and moist in shock. d) Increased urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Description : The nurse recognizes which of the following signs as typical of the patient in shock? a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate. b) Flushed face Pallor is ... urine output Usually, a low blood pressure and concentrated urine are observed in the patient in shock.

Last Answer : a) Rapid, weak, thready pulse Pulse increases as the body tries to compensate.

A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Description : A staff nurse was found charting blood glucose result without actually doing the procedure. What is the appropriate initial action of the senior nurse? A. Write and submit an explanation and reprimand as necessary B. Go on leave without pay C. Write an incident report D. Explain to the patient

Last Answer : A. Write and submit an explanation and reprimand as necessary

Which of the following statements reflect current research regarding the utilization of non-pharmacological measures in the management of burn pain? a) Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the patient’s attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It also allows for patient self-expression.

Description : Which of the following statements reflect current research regarding the utilization of non-pharmacological measures in the management of burn pain? a) Music therapy may provide reality orientation, distraction, ... of burn pain. Pet therapy has not proven effective in the management of burn pain.

Last Answer : a) Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience ... orientation, distraction, and sensory stimulation. It also allows for patient self-expression.

An 18-year-old man shot once in the left chest has a blood pressure of 80/50 mm. Hg, a heart rate of 130 beats per minute, and distended neck veins. Immediate treatment might include: A. Administration of one liter of Ringer's lactate solution. B. Subxiphoid pericardiotomy. C. Needle decompression of the left chest in the second intercostal space. D. Emergency thoracotomy to cross-clamp the aorta.

Description : An 18-year-old man shot once in the left chest has a blood pressure of 80/50 mm. Hg, a heart rate of 130 beats per minute, and distended neck veins. Immediate treatment might include: A. ... of the left chest in the second intercostal space. D. Emergency thoracotomy to cross-clamp the aorta.

Last Answer : Answer: AC DISCUSSION: The finding of distended neck veins in conjunction with hypotension should suggest tension pneumothorax or pericardial tamponade. Absent ipsilateral breath sounds and a trachea ... injuries. There is no role for aortic cross-clamping in this scenario of cardiogenic shock

Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

Description : Which of the following nursing interventions is appropriate when caring for the awake and oriented head injury patient? a) Supply oxygen therapy to keep blood gas values within normal range. ... rails and application of mitts are the appropriate interventions in the agitated head-injured patient.

Last Answer : a) Supply oxygen therapy to keep blood gas values within normal range. The goal is to keep blood gas values within normal range to ensure adequate cerebral circulation.

Most skin conditions related to HIV disease may be helped primarily by a) highly active antiretroviral therapy (HAART). The goals of all HIV-related conditions include improvement of CD4 count and lowering of viral load. Initiation of HAART (highly active antiretroviral therapy) will help improve most skin conditions related to HIV disease. Symptomatic relief will be required until the skin condition improves.

Description : Most skin conditions related to HIV disease may be helped primarily by a) highly active antiretroviral therapy (HAART). The goals of all HIV-related conditions include improvement of CD4 count and ... for the overall treatment of HIV disease; it is not specific for treatment of skin conditions.

Last Answer : a) highly active antiretroviral therapy (HAART). The goals of all HIV-related conditions include improvement of CD4 count and lowering of viral load. Initiation of HAART (highly active ... conditions related to HIV disease. Symptomatic relief will be required until the skin condition improves.

75. At the start of thyroid replacement post-total thyroidectomy, the nurse must monitor for side effects. Which side effects would the nurse expect to assess? 1. Hypertension 2. Tremors 3. Hirsutism 4. Insomnia 5. Tachycardia 6. Hyperglycemia

Description : 75. At the start of thyroid replacement post-total thyroidectomy, the nurse must monitor for side effects. Which side effects would the nurse expect to assess? 1. Hypertension 2. Tremors 3. Hirsutism 4. Insomnia 5. Tachycardia 6. Hyperglycemia

Last Answer : A. 3, 4, 5, and 6

Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

Description : Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs ... pain at the recipient site is anticipated since the wound has been protected by the graft.

Last Answer : a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.