The nurse is caring for a patient who is diaphoretic from a fever. The amount of sodium excreted in the urine will:

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Decrease. When a patient is diaphoretic from a fever, they are losing fluids through sweating, leading to a decrease in total body fluid volume. As a compensatory mechanism, the body tries to retain as much sodium and water as possible to maintain fluid balance and prevent dehydration. Option B) Increase is incorrect because the body's response to diaphoresis is to conserve sodium, not excrete more of it. Option C) Remain unchanged is incorrect because the body needs to retain sodium to compensate for fluid loss. Option D) Fluctuate is incorrect as there is a clear physiological response to sweating and fever that leads to a decrease in sodium excretion. Educationally, understanding the relationship between fever, diaphoresis, and sodium excretion is crucial for nurses caring for patients with fluid and electrolyte imbalances. This knowledge helps nurses anticipate and manage potential complications related to fluid loss and electrolyte disturbances in various clinical settings.

Correct Answer: D

Rationale: In this scenario, the correct interpretation of the arterial blood gas results provided is "D) Metabolic acidosis with a compensatory respiratory alkalosis." This interpretation is based on understanding the body's compensatory mechanisms when there is an imbalance in acid-base status. The pH of 7.26 indicates acidosis, the low PaCO2 of 28 suggests respiratory alkalosis (as it is below the normal range of 35-45 mmHg), and the low HCO3 of 11 indicates metabolic acidosis. In this case, the primary disorder is metabolic acidosis, as evidenced by the low HCO3, and the compensatory response is a decrease in PaCO2 to try to raise the pH back towards normal levels, resulting in a compensatory respiratory alkalosis. Option A is incorrect because there is evidence of metabolic acidosis in addition to the respiratory alkalosis. Option B is incorrect as there is no evidence of metabolic alkalosis. Option C is incorrect as there is evidence of both metabolic acidosis and respiratory alkalosis, indicating compensation. Understanding arterial blood gas results is crucial in medical-surgical nursing as it helps nurses identify and manage acid-base imbalances, guiding appropriate interventions and treatment plans to restore balance and improve patient outcomes. Nurses need to interpret these results accurately to provide safe and effective care to patients with complex physiological disturbances.

Correct Answer: C

Rationale: Infiltration is the administration of nonvesicant solution or medication into the surrounding tissue. This can occur when the IV cannula dislodges or perforates the wall of the vein. Infiltration is characterized by edema around the insertion site, leakage of IV fluid from the insertion site, discomfort and coolness in the area of infiltration, and a significant decrease in the flow rate.

Correct Answer: C

Rationale: In the context of medical surgical nursing, the best initial nursing action prior to inserting an IV is to verify the order for IV therapy (Option C). This step is crucial as it ensures that the IV therapy is appropriate for the patient's condition and has been prescribed by the healthcare provider. Verifying the order also helps prevent medication errors and ensures patient safety. The other options are not the best initial nursing actions prior to inserting an IV. Option A, having the patient wash their hands, is important for infection control but is not directly related to the insertion of an IV. Option B, preparing the IV insertion site with povidone iodine, is a step that comes after verifying the order for IV therapy and identifying a suitable vein. It is important for maintaining asepsis during the procedure. Option D, identifying a suitable vein, is an important step in the IV insertion process, but verifying the order for IV therapy takes precedence as it ensures that the IV is necessary and appropriate for the patient. In an educational context, understanding the sequence of steps in IV therapy is essential for safe and effective patient care. Verifying the order for IV therapy is a fundamental nursing responsibility that helps prevent errors and promote positive patient outcomes. It is important for nursing students to prioritize patient safety and follow established protocols when performing procedures such as IV insertion.

Correct Answer: B

Rationale: The correct answer to the question is option B: "Only relatively large volumes of air administered rapidly are dangerous." This response is the best choice because it provides accurate information to the patient regarding the risk of air bubbles in IV tubing. In reality, small amounts of air bubbles in IV tubing are generally not harmful to patients as they are absorbed and eliminated by the body. It is only when a significant volume of air is rapidly infused that it can potentially cause harm by obstructing blood flow in small vessels or leading to air embolism. Option A, stating that the system is closed and it is impossible for air bubbles to enter the IV tubing, is incorrect as air bubbles can indeed form in IV tubing due to various factors such as improper priming, tubing connections, or changes in pressure. Option C, mentioning a risk of complication with IV administration, is vague and does not directly address the patient's concern about air bubbles. Option D is clearly inappropriate and unprofessional, as it dismisses the patient's question without providing any useful information. In an educational context, it is essential for nurses to be able to effectively communicate with patients and provide accurate information to address their concerns. Understanding the implications of air bubbles in IV tubing is crucial for patient safety, and nurses must be able to explain this concept clearly to patients to alleviate any fears or misconceptions. By choosing option B, the nurse can educate the patient about the actual risks associated with air bubbles in IV tubing and promote an informed understanding of the situation.