The picture below is an assessment finding of a nurse. What nursing intervention will the nurse expect to do?

Administer a bolus of 0.9% Normal Saline per physician order

Administer a bolus of 3% Normal Saline per physician order

Walk the patient down the hallway 10 feet

Turn the patient every two hours

Answer and Explanation

The Correct Answer is A

A. Administer a bolus of 0.9% Normal Saline per physician order: The image shows poor skin turgor, a classic sign of dehydration. Skin that “tents” when pinched indicates fluid volume deficit, requiring isotonic fluid replacement such as 0.9% normal saline to restore intravascular volume.

B. Administer a bolus of 3% Normal Saline per physician order: 3% Normal Saline is hypertonic and reserved for severe hyponatremia or cerebral edema. It is not appropriate for general dehydration and can cause fluid shifts leading to complications if misused.

C. Walk the patient down the hallway 10 feet: Ambulating a dehydrated or volume-depleted patient could worsen hypotension or dizziness, risking falls. Hydration should precede mobility in such cases.

D. Turn the patient every two hours: Repositioning every 2 hours is important for pressure injury prevention but does not address the underlying issue of dehydration evident in the assessment finding.

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Correct Answer is B

Explanation

A. determine the amount of protein binding of the drug: Protein binding affects the drug’s activity and distribution, but peak and trough levels specifically measure blood concentration, not protein binding.

B. determine if the blood concentration is at a level to produce beneficial effects: Peak and trough levels are used to ensure the drug concentration stays within a therapeutic range—high enough to be effective but low enough to avoid toxicity. This monitoring is crucial for drugs with narrow therapeutic windows.

C. measure the distribution of the drug throughout the body: Drug distribution refers to how a drug spreads to tissues and organs, which is not directly assessed by peak and trough blood levels.

D. measure the first pass effect: The first pass effect relates to drug metabolism by the liver before reaching systemic circulation, which is not evaluated by peak and trough drug level measurements.

A. poor tissue repair. B. difficulty with memory. C. increased susceptibility to disease. D. gastrointestinal upset.

Correct Answer is B

Explanation

A. poor tissue repair: Tissue repair mainly occurs during deep (slow-wave) sleep rather than REM sleep, so deprivation of REM sleep is less likely to directly impair this process.

B. difficulty with memory: REM sleep plays a critical role in cognitive functions such as memory consolidation and learning. Continuous deprivation of REM sleep can significantly impair memory retention and cognitive performance.

C. increased susceptibility to disease: While overall sleep deprivation can weaken the immune system, REM sleep deprivation specifically has a more pronounced effect on brain function than direct immune defense.

D. gastrointestinal upset: Gastrointestinal symptoms are not typically linked to REM sleep deprivation but may be associated with general stress or other sleep disorders.

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The picture below is an assessment finding of a nurse. What nursing intervention will the nurse expect to do?

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Naxlex Comprehensive Predictor Exams

A patient is to have peak and trough levels drawn for a particular drug. The nurse explains to the patient that these drug blood levels are important to:

Correct Answer is B

Explanation

The nurse understands that patients who are continuously deprived of REM sleep are at highest risk for:

Correct Answer is B

Explanation

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Medications that are taken by mouth (swallowed)

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