Nur 255 B Adult Health 1 CBU

Correct Answer: "My eyelids droop, and I see double everything."

Myasthenia Gravis (MG) is a neuromuscular disorder characterized by muscle weakness and fatigue. One of the hallmark symptoms of MG is ptosis (drooping eyelids) and diplopia (double vision).

These symptoms occur because of impaired communication between the nerve and the muscle, specifically affecting the ocular muscles. The patient’s complaint about drooping eyelids and seeing double is highly suggestive of MG, supporting the diagnosis.

Why the Other Options Are Incorrect:

"I get chest pain and faint after I walk in the hall."

Chest pain and fainting are not typical symptoms of myasthenia gravis. These symptoms could indicate a cardiovascular issue such as angina or orthostatic hypotension, which are not directly associated with MG.

"I gained 3 pounds this week, and I am spitting up pink frothy sputum."

Weight gain and pink, frothy sputum are more concerning for heart failure or pulmonary edema rather than myasthenia gravis. While MG can affect breathing muscles, it typically causes progressive muscle weakness rather than fluid accumulation in the lungs.

"I have weakness and fatigue in my feet and legs."

Weakness and fatigue are common symptoms of MG, but the ocular symptoms (drooping eyelids and double vision) are more specific to the diagnosis. Weakness and fatigue in the lower extremities could be caused by other conditions, such as peripheral neuropathy or musculoskeletal disorders, and would not be as specific to MG.

Summary:

The correct statement that supports the diagnosis of myasthenia gravis is "My eyelids droop, and I see double everything" because these are classic signs of ocular muscle weakness, a hallmark of MG.

Correct Answer: Metformin (Glucophage)

Metformin, an oral biguanide used to treat type 2 diabetes, should be withheld for 24 hours before and 48 hours after procedures involving contrast dye (such as a cardiac catheterization).

This is because the use of contrast dye can increase the risk of acute kidney injury (AKI), and Metformin can further increase the risk of lactic acidosis in patients with compromised renal function, especially after the procedure.

Why the Other Options Are Incorrect:

Regular insulin:

Regular insulin is a short-acting insulin used to control blood glucose levels in diabetic patients. It is not specifically contraindicated for withholding before or after cardiac catheterization. In fact, insulin may be adjusted around the procedure, but it is not withheld as Metformin is. Insulin is usually adjusted based on blood glucose levels, not necessarily withheld for a procedure.

Repaglinide (Prandin):

Repaglinide is a meglitinide that works by stimulating insulin release from the pancreas. It is typically taken with meals to control postprandial blood sugar. It does not carry the same risk of lactic acidosis as Metformin, so it is not necessary to withhold this medication before or after the procedure unless specifically instructed by the healthcare provider.

Glipizide (Glucotrol):

Glipizide is a sulfonylurea that helps the body release more insulin. Like repaglinide, it does not have the same risk as Metformin related to kidney function or lactic acidosis after contrast procedures. It may be adjusted around the procedure based on blood glucose, but withholding it for 24 hours before and 48 hours after the procedure is not generally necessary.

Summary:

Metformin should be withheld for 24 hours before and 48 hours after a cardiac catheterization procedure due to the risk of lactic acidosis and acute kidney injury when used with contrast dye. Other diabetes medications like insulin, repaglinide, and glipizide do not carry the same risks and are not typically withheld in preparation for this procedure.

Correct Answer: Continue to monitor the patient

The decrease in hematocrit from 48% to 46% on the second postoperative day is a small change and may not indicate an immediate problem. Hematocrit levels can fluctuate slightly due to factors like fluid balance or changes in plasma volume post-surgery.

As the hemoglobin remains steady, this suggests that there is no significant blood loss at this time. Continuing to monitor the patient is the most appropriate course of action, as further testing or interventions might not be necessary unless there are other signs of complications.

Why the Other Options Are Incorrect:

Check the surgical site for increased bleeding:

While it’s important to monitor for signs of bleeding post-surgery, a slight decrease in hematocrit alone (without other signs of active bleeding such as a drop in hemoglobin or clinical symptoms like tachycardia or hypotension) does not immediately indicate increased bleeding. Therefore, checking for bleeding is not the priority unless other signs of blood loss are present.

Administer oxygen at 2 L/min:

There is no evidence of hypoxia or respiratory distress in this scenario. The steady hemoglobin level and the small hematocrit decrease do not necessitate the administration of oxygen. Oxygen would only be required if the patient is showing signs of respiratory distress or hypoxia.

Increase the IV flow rate:

There is no indication of hypovolemia or dehydration that would require an increase in the IV flow rate. In fact, over-hydration could lead to further dilution of blood components. Monitoring for any symptoms of fluid imbalance is a more appropriate approach at this time.

Summary:

The correct response is Continue to monitor the patient. A slight decrease in hematocrit without any change in hemoglobin or other symptoms typically does not require immediate intervention. Monitoring the patient’s status for any changes is the best approach.

The correct answer is: C) 1.5-2.5 times the normal range

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  When a patient is receiving continuous IV heparin for a condition such as a pulmonary embolism, the aPTT (activated partial thromboplastin time) is used to monitor the effectiveness and safety of the heparin therapy.

  
  


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  Heparin therapy is usually aimed at achieving an aPTT that is 1.5 to 2.5 times the normal range. This ensures the medication is effectively preventing further clotting without increasing the risk of bleeding too much.

  
  

Why the Other Options Are Incorrect:

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   A) Less than 1:

   
   
   
   
   
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     This is not a viable answer because it would indicate that the blood is clotting too quickly, meaning the heparin is not effective at all. The aPTT should be elevated, not low, during heparin therapy.

     
     
   
   
   
   


2. 
   

   B) 2-3 seconds:

   
   
   
   
   
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     This is too short of a time for aPTT and does not apply to monitoring heparin therapy. The aPTT value should be extended, not close to the normal range.

     
     
   
   
   
   


3. 
   

   D) 30-40 seconds:

   
   
   
   
   
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     This is the normal aPTT range for an individual not on anticoagulation therapy. For heparin therapy, the aPTT should be much longer than this to be effective, which is why the value should be 1.5 to 2.5 times the normal range.

     
     
   
   
   
   

Summary:

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  For a patient on a continuous IV heparin drip for pulmonary embolism treatment, the aPTT should be 1.5 to 2.5 times the normal range to ensure proper anticoagulation and effective therapy. The other options either don't reflect the required therapeutic range or are unrelated to aPTT monitoring for heparin.

  
  

Correct Answers:

Pain controlled

Stable vital signs

No nausea or dizziness

Adequate urine output

When preparing to discharge a patient after outpatient surgery, the nurse must assess whether the patient has met specific criteria indicating they are ready to safely leave the healthcare facility. These criteria include:

Pain controlled: The patient should have their pain under control, typically with the use of oral medications, and should be able to manage pain independently once at home.

Stable vital signs: Vital signs such as blood pressure, heart rate, respiratory rate, and temperature should be within normal limits and stable after surgery to ensure the patient is not at risk for immediate complications.

No nausea or dizziness: The absence of nausea or dizziness is crucial, as these symptoms could interfere with the patient's ability to safely leave the facility or manage self-care after surgery. Dizziness, in particular, could indicate issues like hypotension or sedation from anesthesia.

Adequate urine output: Adequate urine output indicates proper kidney function and the return of normal fluid balance post-surgery. This is particularly important in cases where surgery involved anesthesia or the use of fluids that could affect kidney function.

Why the Other Option is Not Correct:

Family member's eagerness to go home: While it's important to consider the patient's support system, the decision to discharge should be based on the patient's physical readiness to go home rather than the family member's desire to leave. The patient's well-being is the priority.

Summary:

The nurse must ensure the patient meets several criteria before discharge, focusing on physiological stability and ensuring the patient can safely manage at home.

Correct Answer: Skin

"Insensible fluid loss" refers to the fluid loss that occurs through the skin and respiratory tract that is not easily measurable or visible. This includes:

Skin: Fluid lost through evaporation from the skin, which is typically not noticeable unless there is excessive sweating or environmental factors (like heat).\

Respiratory tract: Fluid lost as water vapor during breathing, which is also not directly measurable unless significant changes in respiratory function occur.

Why the other options are less likely:

Urine: Urine output is a measurable and sensible form of fluid loss. It's not considered insensible because it can be quantified.

Wound drainage: This type of fluid loss is sensible, as it is visible and can be measured, making it distinct from insensible fluid loss.

Gastrointestinal (GI) tract: Fluid loss from the GI tract (e.g., diarrhea, vomiting) is also considered sensible because it is observable and measurable.

Key Point:

Insensible fluid loss is often underestimated and can be significant, particularly in conditions like fever, hyperventilation, or excessive sweating. It's important for healthcare providers to consider this type of fluid loss when assessing a patient's overall fluid status.

Correct Answer: Regular (Humulin R) insulin

Regular insulin (Humulin R) is the only type of insulin that can be administered intravenously (IV). It is a short-acting insulin, which makes it suitable for rapid control of blood glucose levels in emergency situations such as diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS).

Why the Other Options Are Incorrect:

Glargine (Lantus) insulin:

Glargine is a long-acting insulin that is not suitable for IV administration. It is designed to provide a steady, basal level of insulin and is typically injected subcutaneously.

NPH (Humulin N) insulin:

NPH is an intermediate-acting insulin and also cannot be given IV. Like glargine, it is intended for subcutaneous injection to provide longer-term control of blood glucose.

Lispro (Humalog) insulin:

Lispro is a rapid-acting insulin, but it is typically given subcutaneously rather than intravenously. While it has a quick onset of action, it is not formulated for IV use.

Summary:

For IV administration, regular insulin (Humulin R) is preferred because of its rapid action and ability to quickly reduce blood glucose levels.