Nokea
A client was brought to the emergency room with complains of difficulty of breathing. What can lead the nurse to suspect that the client is experiencing acute respiratory distress syndrome (ARDS)?
- A. paO2 of 95, pCO2 of 43, x-ray showing enlarged heart, bradycardia
- B. Thick green sputum production, paO2 of 74, pH of 7.41
- C. restlessness, suprasternal retractions, paO2 of 62
- D. wheezes, slow, deep respirations, pCO2 of 52, pH of 7.35
Correct Answer: C
Rationale: Step-by-step rationale for choice C being correct:
1. Restlessness: Indicates increased work of breathing and hypoxia.
2. Suprasternal retractions: Sign of respiratory distress.
3. paO2 of 62: Indicates severe hypoxemia, common in ARDS.
Summary:
A: Enlarged heart on x-ray does not directly indicate ARDS.
B: Thick green sputum suggests infection, not specific to ARDS.
D: Wheezes and slow respirations are not typical of ARDS, and pCO2 is normal in ARDS.
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With pulmonary edema, there is usually an alteration in:
- A. Afterload
- B. Preload
- C. Contractility
- D. All of the above
Correct Answer: D
Rationale: Pulmonary edema causes an increase in pressure in the pulmonary circulation, leading to an alteration in afterload due to increased resistance. It also causes fluid accumulation in the pulmonary vessels, affecting preload. Additionally, the heart may compensate by increasing contractility. Therefore, all of the above choices are altered in pulmonary edema. The incorrect choices are A, B, and C individually as they only represent one aspect of the alterations seen in pulmonary edema, while the correct answer D encompasses all three factors affected in this condition.
On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment?
- A. Radiation therapy
- B. Chemotherapy
- C. Major surgery
- D. None
Correct Answer: C
Rationale: The correct initial treatment for stage IV ovarian cancer is major surgery (Choice C). This is because at this advanced stage, surgery is typically performed to debulk the tumor and remove as much cancerous tissue as possible, followed by chemotherapy to target any remaining cancer cells. Radiation therapy (Choice A) is not typically the initial treatment for ovarian cancer. Chemotherapy (Choice B) is often used in combination with surgery, but surgery is usually the first line of treatment for stage IV disease. Choosing no treatment (Choice D) would be detrimental as the cancer is advanced and requires immediate intervention.
Which of the following risk factors presents the greatest threat for respiratory disease?
- A. Smoking
- B. Exposure to radiation
- C. High-fat diet
- D. Alcohol consumption
Correct Answer: A
Rationale: The correct answer is A: Smoking. Smoking presents the greatest threat for respiratory disease due to the harmful chemicals in tobacco that can damage the lungs and lead to conditions like COPD and lung cancer. Smoking is a well-known risk factor for various respiratory issues. Exposure to radiation (B) can increase cancer risk but is not as directly linked to respiratory diseases. High-fat diet (C) may impact overall health but is not a primary risk factor for respiratory diseases. Alcohol consumption (D) can contribute to respiratory issues, but smoking is considered the most significant risk factor.
The nurse will monitor J.E. for the following signs and symptoms:
- A. Change in the levei of consciousness, tachypnea, tachycardia, petechiae
- B. Onset of chest pain, tachycardia, diaphoresis, nausea and vomiting
- C. Loss of consciousness, bradycardia, petechiae, and severe leg pain
- D. Change in leve! of consciousness, bradycardia, chest pain and oliguria
Correct Answer: A
Rationale: The correct answer is A because signs and symptoms listed are indicative of disseminated intravascular coagulation (DIC), which is a serious condition where blood clotting and bleeding occur simultaneously. Change in level of consciousness can indicate hypoperfusion from clotting in blood vessels. Tachypnea and tachycardia can result from tissue hypoxia. Petechiae are small red or purple spots on the skin due to bleeding under the skin.
Choices B, C, and D are incorrect because they do not align with the typical signs and symptoms of DIC. Choice B suggests a possible myocardial infarction or acute coronary syndrome. Choice C indicates a possible thrombotic thrombocytopenic purpura (TTP) or acute limb ischemia. Choice D suggests a mix of symptoms that do not typically present together in DIC.
. A client with a suspected left sided heart failure is scheduled to undergo a multigated acquisition scan. Which of the following actions is required before undergoing the test?
- A. Diuretics are administered
- B. Client should avoid fluid intake 6 hours
- C. Client is medicated to relieve cough before the test
- D. Client is administered analgesics
Correct Answer: C
Rationale: Rationale:
- A: Diuretics are not necessary before the test and may affect test results.
- B: Dehydration is not recommended before the test as it can impact cardiac function.
- C: Medication to relieve cough is necessary to reduce any potential interference with the scan.
- D: Administering analgesics is not required for the test and may not be relevant to the client's condition.