An 85-year-old patient who has fallen at home and was unable to get up is admitted to your nursing unit. The patient said she fell 36 hours ago and has been unable to eat or drink. You observe that the patient has voided scant amounts since admission. In planning care for this patient, what condition do you consider related to the diminished renal output?

Renal calculi

Hypovolemia

inactivity

Nephrotoxic drugs

Answer and Explanation

The Correct Answer is B

A.   While renal calculi (kidney stones) can cause renal issues, they are not directly related to diminished renal output in this scenario. Hypovolemia, or low blood volume, is more pertinent to the patient's presentation of scant voiding and inability to eat or drink.
B.   Diminished renal output, as evidenced by scant voiding, can be indicative of hypovolemia. Hypovolemia reduces kidney perfusion, leading to decreased urine output as the kidneys conserve fluid.
C.   While inactivity can contribute to various health issues, it's not directly related to diminished renal output in this case. The primary concern is addressing the immediate physiological impact of decreased renal function.

D.   While nephrotoxic drugs can impair renal function, there's no indication in the scenario that the patient has been exposed to such drugs. Thus, they are not directly relevant to the current situation.

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Correct Answer is A

Explanation

A. Atrial flutter is characterized by a regular rhythm with rapid atrial contractions (flutter waves) that have a sawtooth appearance on the ECG tracing.
B. Ventricular tachycardia typically presents with a wide QRS complex and is often associated with hemodynamic instability.
C. Atrial fibrillation is characterized by irregularly irregular rhythm with no distinct P waves and irregular ventricular response.
D. Sinus tachycardia is characterized by a regular rhythm with a heart rate greater than 100 beats per minute originating from the sinus node.

A. Swab teeth and mucous membranes four times daily with lemon-glycerin swabs B. Brush teeth twice a day with a firm toothbrush C. Use sponge Toothettes to clean teeth between meals D. Use waxed floss between meals and at bedtime

Correct Answer is C

Explanation

A. Lemon-glycerin swabs can dry out and irritate oral tissues, increasing the risk of oral mucositis and infection.
B. Using a firm toothbrush may be too harsh for irritated mucous membranes and can increase the risk of injury and bleeding.
C. Gentle oral care is essential to avoid further irritation of the mucous membranes.

D. Flossing may be too abrasive for irritated mucous membranes and can increase the risk of bleeding and injury.

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Naxlex Comprehensive Predictor Exams

The nurse is reading a cardiac monitor of a patient and observes a regular rhythm, and the P waves have a sawtooth pattern. The nurse recognizes this as which arrhythmia?

Correct Answer is A

Explanation

A patient receiving chemotherapy for chronic myelocytic leukemia has irritates mucous membranes. Which of the following mouth care interventions would the nurse include in the plan of care?

Correct Answer is C

Explanation

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What discharge teaching is most important to help the patient who has had a splenectomy prevent infection?

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