ATI RN
Burns Pediatric Primary Care 7th Edition Test Bank Questions
Question 1 of 5
A patient returns from surgery ff. a TURP with a three-way Foley catheter and continuous bladder irrigation. Postoperative orders include Meperidine (Demerol) 75 mg IM q3h as needed for pain, belladonna and opium (B&O) suppository q4h as needed, and strict I&O. the patient complains of painful bladder spasms, and the nurse observes blood-tinged urine on the sheets. Which action should the nurse take?
Correct Answer: D
Rationale: The nurse should notify the physician stat in this situation. The presence of blood-tinged urine and painful bladder spasms in a patient with a three-way Foley catheter and continuous bladder irrigation post TURP could indicate a potential complication such as hemorrhage or clot retention. It is crucial to ensure prompt medical evaluation and intervention to address these issues effectively. Waiting or administering pain medication without further assessment could delay necessary treatment and lead to worsening of the patient's condition. Therefore, notifying the physician immediately is the most appropriate action in this scenario.
Question 2 of 5
A nurse is directed to administer a hypotonic intravenous solution. The nurse expects that compensatory mechanisms associated with hypovolemia would cause all of the following symptoms except:
Correct Answer: C
Rationale: Hypotonic solutions have lower osmolarity compared to the intracellular fluid, causing water to move into the cells by osmosis. This can lead to further swelling of the cells in the body. In the case of hypovolemia, the body is already experiencing a deficit of fluid and electrolytes, so administering a hypotonic solution like 0.90% sodium chloride would further exacerbate cellular swelling and potentially lead to cellular damage. Therefore, using 0.90% sodium chloride as a compensatory mechanism for hypovolemia would not be appropriate.
Question 3 of 5
Choose the condition that exhibits blood values with a low pH and a high PCO :
Correct Answer: A
Rationale: Respiratory acidosis is a condition characterized by elevated levels of carbon dioxide (high PCOâ‚‚) and decreased blood pH (low pH) due to inadequate ventilation leading to the accumulation of carbon dioxide in the body. The excess carbon dioxide reacts with water in the blood to form carbonic acid, resulting in a decrease in pH. This is in contrast to metabolic acidosis, which is characterized by an accumulation of acids other than carbon dioxide, leading to a low blood pH. Respiratory alkalosis would present with a low PCOâ‚‚ and high pH, while metabolic alkalosis features a high pH and elevated bicarbonate levels due to non-respiratory causes.
Question 4 of 5
What size of suction catheter would Wilma use for James, who is 6 feet 5 inches in height and weighing approximately 145 lbs?
Correct Answer: C
Rationale: The correct size of a suction catheter is usually determined by the patient's weight, rather than height. For James, who weighs approximately 145 lbs, a Fr. 10 suction catheter would be suitable. Suction catheter sizes typically range from Fr. 5 (smaller) to Fr. 18 (larger), with Fr. 10 being a common size for an adult patient of James' weight. Using a catheter that is too small may not effectively clear secretions, while one that is too big may cause discomfort or damage to the airways.
Question 5 of 5
Which patient should be monitored most closely for dehydration?
Correct Answer: A
Rationale: A patient with an ileostomy has an increased risk of dehydration because the ileostomy bypasses a significant portion of the small intestine where most of the water absorption occurs. As a result, the patient is more likely to experience fluid and electrolyte imbalances, leading to dehydration. It is important to monitor this patient closely for signs and symptoms of dehydration, such as decreased urine output, dry mouth, dark-colored urine, weakness, dizziness, and confusion, and take appropriate measures to ensure adequate hydration.