The nurse identifies the diagnosis of Deficient Fluid Volume as appropriate for a patient with a nasogastric tube for gastric decompression. Which actions should the nurse perform to support this diagnosis? Select all that apply.- Skildor

Question 1 of 5

The nurse identifies the diagnosis of Deficient Fluid Volume as appropriate for a patient with a nasogastric tube for gastric decompression. Which actions should the nurse perform to support this diagnosis? Select all that apply.

A. Measure abdominal girth every 4 to 8 hours B. Provide the patient with generous amounts of oral fluids C. Keep an accurate record of intake and output every 2 to 4 hours D. Document the amount and color of nasogastric tube drainage every shift e. Listen to bowel sounds before checking the placement of the nasogastric tube

Correct Answer: A

Rationale: A. Measuring abdominal girth every 4 to 8 hours is important to monitor for signs of fluid accumulation in the abdominal cavity, indicating potential fluid volume deficit.

Question 2 of 5

A school-age client with a history of multiple allergies is prescribed epinephrine (EpiPen�) for prevention of anaphylactic shock. The client's mother says to the nurse, "I thought shock was about heart failure." Which response by the nurse is the most appropriate?

A. "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." B. "Heart failure is the most serious kind of shock; others include infection, kidney failure, and loss of blood." C. "There are many kinds of shock that also include infection, nervous system damage, and loss of blood." D. "There are many kinds of shock: heart failure, nervous system damage, loss of blood, and respiratory failure."

Correct Answer: A

Rationale: The most appropriate response by the nurse is Option A, "Allergic response is the most fatal type of shock; other types involve loss of blood, heart failure, and liver failure." This response is accurate because anaphylactic shock, which is caused by severe allergic reactions, can be life-threatening if not treated promptly with epinephrine (EpiPen�). While heart failure is a serious type of shock, anaphylactic shock is specifically related to severe allergic reactions and not heart failure. The nurse's response educates the mother about the seriousness of anaphylactic shock in relation to allergic responses and highlights that other types of shock can involve different organ system failures.

Question 3 of 5

The nurse is assessing an adult client with a cardiac dysrhythmia. Which finding would the nurse identify as possibly contributing to this client's dysrhythmia?

A. Drinks caffeinated coffee in the morning and for lunch B. Does not smoke or ingest any alcohol C. Plays golf three times a week and gardens daily D. Takes antihypertensive medication as prescribed

Correct Answer: A

Rationale: Consuming caffeinated coffee can potentially contribute to cardiac dysrhythmias in susceptible individuals. Caffeine is a stimulant that can increase heart rate and blood pressure, leading to arrhythmias in some people. Regular intake of caffeinated beverages can disrupt the normal electrical activity of the heart, especially in those with underlying cardiac conditions. Therefore, the nurse would identify drinking caffeinated coffee as a possible contributing factor to the client's dysrhythmia.

Question 4 of 5

Which theory of learning holds that knowledge acquisition is the ongoing assimilation and accommodation of new experiences and interpretations?

A. Constructivist B. Behaviorist C. Social learning D. Cognitive

Correct Answer: A

Rationale: The theory of constructivism holds that knowledge acquisition is the ongoing assimilation and accommodation of new experiences and interpretations. This theory emphasizes that learners actively construct their knowledge and understanding of the world through their experiences and interactions. In constructivism, learning is seen as a process of building upon prior knowledge, rather than passively receiving information. Learners are encouraged to explore, question, and make sense of new information based on their existing beliefs and experiences. Therefore, the constructivist theory aligns with the idea that learning involves the assimilation and accommodation of new experiences and interpretations.

Question 5 of 5

The nurse is caring for a pregnant woman with congenital heart disease. The woman asks if she will be able to have a vaginal delivery. Which answer by the nurse is correct?

A. A Cesarean section is preferred because you will lose less blood than with a vaginal birth. B. A Cesarean section is preferred because there is a lower risk of infection than with a vaginal birth. C. A vaginal birth is preferred over a Cesarean section for women who have aortic stenosis. D. A vaginal birth is preferred because there is a lower risk of thrombophlebitis than with a Cesarean section.

Correct Answer: C

Rationale: A vaginal birth is preferred over a Cesarean section for women who have aortic stenosis. Aortic stenosis is a type of congenital heart disease that restricts blood flow from the heart to the rest of the body due to a narrowing of the aortic valve. In women with aortic stenosis, the increased blood volume and heart rate during labor and delivery can put extra strain on the heart. However, in most cases, vaginal delivery is preferred over a Cesarean section to avoid the risks associated with major abdominal surgery, such as bleeding, infection, and thrombophlebitis. A vaginal birth allows for a more gradual and controlled increase in cardiac output compared to the more sudden changes that can occur during a Cesarean section. Additionally, the stress of labor may mimic the stress test for some patients, providing valuable information about their heart function. However, each case is unique and must be evaluated by the healthcare team

Transcultural Concepts in Nursing Care Test Bank

Skildor

ATI RN

ATI RN

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