The nurse gets hand-off report on four patients. Which patient would the nurse assess first?

Patient with urine output of 40 mL/hr for the last hour.

Patient with a blood pressure change of 128/74 to 110/88 mmHg.

Patient with oxygen saturation maintained at 94%.

Patient with a pulse change of 100 to 88 beats/min.

Answer and Explanation

The Correct Answer is B

Choice A reason: A urine output of 40 mL/hr is within the acceptable range, as normal urine output is typically around 30-50 mL/hr. While it should be monitored, it does not indicate an immediate life-threatening issue requiring urgent assessment.

Choice B reason: A blood pressure change from 128/74 to 110/88 mmHg may indicate potential hemodynamic instability. Although the systolic blood pressure has decreased, the diastolic pressure has increased, which can be concerning. This patient may be at risk for developing more significant blood pressure changes or other complications, making this situation the highest priority for assessment.

Choice C reason: An oxygen saturation level of 94% is generally considered acceptable. While it is on the lower end of the normal range, it does not indicate an immediate life-threatening condition. Continuous monitoring is important, but it is not the most urgent situation compared to the blood pressure change.

Choice D reason: A pulse change from 100 to 88 beats/min represents a decrease in heart rate but remains within the normal range for adult heart rate (60-100 beats/min). While this change should be noted and monitored, it is not as urgent as the blood pressure change that may indicate hemodynamic instability.

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Correct Answer is ["A","B","D","E"]

Explanation

Choice A reason: Not needing vascular access to perform PD is a significant advantage for patients. Peritoneal dialysis uses the peritoneal membrane in the abdomen as a filter to clean the blood, which eliminates the need for vascular access, such as fistulas or catheters required in hemodialysis. This can reduce the risks associated with vascular access, such as infections and complications related to surgical procedures.

Choice B reason: Being able to perform PD in the comfort of one's home is a major benefit. Patients can manage their dialysis treatments at home, which offers more convenience and flexibility compared to traveling to a dialysis center for hemodialysis sessions. This can greatly improve the quality of life and reduce the burden of frequent trips to healthcare facilities.

Choice C reason: Stating that there is no risk for infection with PD is inaccurate. While PD offers many benefits, it does carry a risk of peritonitis, an infection of the peritoneal cavity. Patients must be educated on proper technique and hygiene to minimize this risk. Hence, this statement is not accurate and should not be included as an advantage.

Choice D reason: Having flexibility in when to do the exchanges is another benefit of PD. Patients can schedule their dialysis exchanges at times that best fit their lifestyle and daily routines. This flexibility allows for greater independence and freedom compared to the fixed schedules required for in-center hemodialysis.

Choice E reason: PD can take less time than hemodialysis treatments, especially when considering travel and waiting times associated with in-center hemodialysis. Although the actual dialysis process for PD requires regular exchanges throughout the day or night, it integrates more seamlessly into daily life, making it a time-efficient option for many patients.

A. Blood pressure. B. Urine output. C. Level of consciousness. D. Specific gravity.

Correct Answer is B

Explanation

Choice A reason: Vasopressin (Desmopressin) is not primarily used to decrease blood pressure. It is an antidiuretic hormone that helps manage diabetes insipidus by reducing urine output. While vasopressin can have vasoconstrictive effects, its primary role in this context is to control urine production, not blood pressure.

Choice B reason: The primary therapeutic outcome of vasopressin (Desmopressin) in a patient with diabetes insipidus is to decrease urine output. Diabetes insipidus leads to excessive urine production and dehydration. Vasopressin acts on the kidneys to increase water reabsorption, thereby reducing urine volume and helping to maintain fluid balance.

Choice C reason: Level of consciousness is not a direct therapeutic outcome of vasopressin (Desmopressin). While managing fluid balance can indirectly affect a patient's overall condition and well-being, vasopressin specifically targets the kidneys to reduce urine output and does not have a direct impact on consciousness levels.

Choice D reason: Specific gravity refers to the concentration of solutes in the urine. While vasopressin can affect the specific gravity by concentrating the urine and reducing volume, the primary therapeutic goal is to manage urine output in patients with diabetes insipidus. The focus is on reducing the excessive urine production rather than altering specific gravity.

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The nurse gets hand-off report on four patients. Which patient would the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? Select all that apply.

Correct Answer is ["A","B","D","E"]

Explanation

A nurse is caring for a patient with a head injury who has developed diabetes insipidus and is receiving vasopressin (Desmopressin). The nurse understands the therapeutic outcome is a decrease in:

Correct Answer is B

Explanation

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