Questions and Answers
Which rationale supports the nurse measuring urine and liquid stool using a graduated container?
Which intervention should the nurse implement for a teen with an eating disorder experiencing an anxiety attack and hyperventilation?
Which process requires energy to move fluids, electrolytes, and other solutes across the semipermeable membrane?
What causes the feeling of thirst according to the nurse?
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Which medication would the nurse expect to administer for a patient with a urine output of 25 mL/hr and a serum potassium level of 6 mEq/L?
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What action indicates that Trousseau's sign test is being performed correctly?
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Study Notes
Urine Output Measurement
- Accurate measurement of urine and liquid stool is essential for patients with fluid balance issues.
- A graduated container is used for precise measurement of all liquid output.
- Color changes in output do not require direct handling.
- Examination for microorganisms necessitates diagnostic tests, not visual assessments.
Anxiety and Respiratory Alkalosis
- Hyperventilation during anxiety attacks can lead to respiratory alkalosis.
- Breathing into a brown paper bag helps retain carbon dioxide and alleviate symptoms.
- Encouraging relaxation or positioning the patient flat is ineffective in this situation.
- Intubation is unnecessary unless severe respiratory failure occurs.
Active Transport vs. Passive Processes
- Active transport is the only process requiring energy to move substances against concentration gradients.
- Passive transport mechanisms include diffusion, osmosis, and filtration, which do not need energy.
Mechanism of Thirst
- Thirst is regulated by hypothalamic receptors that monitor fluid concentration and volume.
- When fluid concentration increases, these receptors stimulate nerve impulses perceived as thirst.
- Thirst originates from physiological changes in body fluid, not simply a human feeling.
Management of Hyperkalemia
- Urine output of less than 30 mL/hr and serum potassium levels of 6 mEq/L suggest hyperkalemia.
- Sodium polystyrene sulfonate is the first-line treatment to lower serum potassium.
- Caution is required with potassium-sparing diuretics like spironolactone, which can worsen hyperkalemia.
- Digoxin assessments are crucial if the patient has electrolyte imbalances to prevent toxicity.
Trousseau's Sign Testing
- Trousseau's sign is demonstrated by inducing muscle spasms through blood pressure cuff inflation, not by the other listed assessments.
- Correct testing involves monitoring for a hand or arm twitch or contraction as a response to hypocalcemia.
- Other assessments described do not pertain to Trousseau's sign specifically.
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Description
Test your knowledge on key nursing interventions and concepts from Chapter 18 of the Foundations textbook. This quiz focuses on measuring patient output and understanding its significance in nursing care. Assess your understanding of the rationale behind various nursing actions.
