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A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?
- A. PCO2 58
- B. SaO2 90
- C. PH 7.23
- D. HCO3 30
Correct Answer: C
Rationale: A pH of 7.23 indicates severe respiratory acidosis, suggesting inadequate ventilation and the need for mechanical ventilation. PCO2 58 (A) and HCO3 30 (D) are elevated but less critical, and SaO2 90 (B) is low but not definitive.
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The nurse is teaching a client with ulcerative colitis who has been prescribed sulfasalazine (Azulfidine). What clinical manifestations will the nurse tell the client to be particularly alert for when taking this drug?
- A. Flu-like symptoms
- B. Purplish rash
- C. Skin blisters
- D. Anorexia
- E. Nausea
Correct Answer: A, B, C, E
Rationale: Sulfasalazine side effects include flu-like symptoms (A), purplish rash (B), skin blisters (C), and nausea (E). Anorexia (D) is less common.
While changing the dressing on a client's central line, the nurse notices redness and warmth at the needle insertion site. Which of the following actions would be appropriate to implement based on this finding?
- A. Discontinue the central line.
- B. Begin a peripheral IV.
- C. Document in the nurse's notes and notify the physician after redressing the site.
- D. Clean the site well and redress.
Correct Answer: C
Rationale: The nurse should always document findings and alert the physician to the findings as well. The physician may then initiate a new central line and order the current central line to be discontinued.
A client with a history of chronic lymphocytic leukemia is admitted with complaints of fever. The nurse should give priority to:
- A. Monitoring for infection
- B. Administering chemotherapy
- C. Monitoring blood pressure
- D. Administering pain medication
Correct Answer: A
Rationale: Fever in chronic lymphocytic leukemia suggests possible infection, a serious complication due to immunosuppression, so monitoring for infection is the priority.
MgSO4 is ordered IV following the established protocol for a client with severe PIH. The anticipated effects of this therapy are anticonvulsant and:
- A. Vasoconstrictive
- B. Vasodilative
- C. Hypertensive
- D. Antiemetic
Correct Answer: B
Rationale: An anticonvulsant effect is the goal of drug therapy for PIH. However, we would not want to increase the vasoconstriction that is already present. This would make the symptoms more severe. An anticonvulsant effect and vasodilation are the desired outcomes when administering this drug. An anticonvulsant effect is the goal of drug therapy for PIH; however, hypertensive drugs would increase the blood pressure even more. An anticonvulsant effect is the goal of drug therapy for PIH. MgSO4 is not classified as an antiemetic. Antiemetics are not indicated for PIH treatment.
The nurse is performing discharge teaching on a client at high risk for the development of skin cancer. Which instruction should be included in the client teaching?
- A. "You should see the doctor every six months."
- B. "Sunbathing should be done between the hours of noon and 3 p.m."
- C. "If you have a mole, it should be removed and biopsied."
- D. "You should wear sunscreen when going outside."
Correct Answer: D
Rationale: Wearing sunscreen protects against UV radiation, a key skin cancer risk factor. Regular checkups (A) are less specific, sunbathing at peak hours (B) increases risk, and routine mole removal (C) is excessive.