Nokea
A diabetic patient's arterial blood gas (ABG) results are pH 7.28; PaCO2 34 mm Hg; PaO2 85 mm Hg; HCO3 18 mEq/L. The nurse would expect which finding?
- A. Intercostal retractions
- B. Kussmaul respirations
- C. Low oxygen saturation (SpO2)
- D. Decreased venous O2 pressure
Correct Answer: B
Rationale: Kussmaul respirations (deep and rapid) are a compensatory mechanism for metabolic acidosis. The low pH and low bicarbonate levels indicate metabolic acidosis. Intercostal retractions, low oxygen saturation, and decreased venous O2 pressure are not associated with acidosis. Intercostal retractions typically occur in respiratory distress, while low oxygen saturation and decreased venous O2 pressure are more related to respiratory or circulatory issues, not metabolic acidosis.
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A 64-year-old patient with amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which nursing action will be included in the plan of care?
- A. Assist with active range of motion (ROM).
- B. Observe for agitation and paranoia.
- C. Give muscle relaxants as needed to reduce spasms.
- D. Use simple words and phrases to explain procedures.
Correct Answer: A
Rationale: In a patient with ALS, progressive muscle weakness is a significant issue. Assisting with active range of motion (ROM) exercises will help maintain muscle strength for as long as possible. Agitation and paranoia are not typically associated with ALS, making choice B incorrect. Giving muscle relaxants can further weaken muscles and depress respirations, worsening the condition, so choice C is inappropriate. Choice D is not directly related to the patient's physical condition and needs.
A 49-year-old patient with multiple sclerosis (MS) is to begin treatment with glatiramer acetate (Copaxone). Which information will the nurse include in patient teaching?
- A. Recommendation to drink at least 4 L of fluid daily
- B. Need to avoid driving or operating heavy machinery
- C. How to draw up and administer injections of the medication
- D. Use of contraceptive methods other than oral contraceptives
Correct Answer: C
Rationale: When initiating treatment with glatiramer acetate (Copaxone), patient education should focus on teaching the patient how to draw up and administer injections of the medication. Copaxone is administered via self-injection, hence understanding the correct technique is crucial for successful treatment. Recommendations regarding fluid intake or the need to avoid driving heavy machinery are not directly related to glatiramer acetate therapy. Additionally, while discussing contraceptive methods may be important, the use of oral contraceptives does not specifically contraindicate the use of glatiramer acetate.
A patient with severe mitral regurgitation and decreased cardiac output is being cared for by a nurse. The nurse assesses the patient for mental status changes. What is the rationale for this intervention?
- A. Decreased cardiac output can cause hypoxia to the brain
- B. Mental status changes may be a side effect of the patient's medication
- C. Mitral regurgitation is a complication associated with some neurological disorders
- D. The patient may be confused about his diagnosis
Correct Answer: A
Rationale: When caring for a patient with severe mitral regurgitation and decreased cardiac output, assessing for mental status changes is crucial. Decreased cardiac output can lead to inadequate perfusion and oxygenation of vital organs, including the brain, resulting in hypoxia. This hypoxia can manifest as mental status changes such as confusion, restlessness, or lethargy. Therefore, monitoring mental status helps in identifying potential hypoxic states and guiding appropriate interventions. The other options are incorrect as they do not directly correlate decreased cardiac output with potential hypoxia-induced mental status changes.
Which information about a 60-year-old patient with MS indicates that the nurse should consult with the healthcare provider before giving the prescribed dose of dalfampridine (Ampyra)?
- A. The patient has relapsing-remitting MS
- B. The patient walks a mile a day for exercise
- C. The patient complains of pain with neck flexion
- D. The patient has an increased serum creatinine level
Correct Answer: D
Rationale: The correct answer is that the patient has an increased serum creatinine level. Dalfampridine should not be given to patients with impaired renal function as it can worsen their condition. Options A, B, and C are unrelated to the administration of dalfampridine. The fact that the patient has relapsing-remitting MS, walks for exercise, or experiences neck pain does not directly impact the decision to administer dalfampridine. However, an increased serum creatinine level is a contraindication for this medication and requires consultation with the healthcare provider to determine the appropriate course of action.
A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance?
- A. Assist the patient to splint the chest when coughing.
- B. Teach the patient about the need for fluid intake.
- C. Encourage the patient to wear the nasal oxygen cannula.
- D. Instruct the patient on the pursed lip breathing technique.
Correct Answer: A
Rationale: Assisting the patient to splint the chest when coughing is the most appropriate action to promote airway clearance in a patient with bacterial pneumonia, rhonchi, and thick sputum. Splinting the chest helps reduce pain during coughing and increases the effectiveness of clearing secretions. Teaching the patient about the need for fluid intake is important as it helps liquefy secretions, aiding in easier clearance. Encouraging the patient to wear a nasal oxygen cannula may improve gas exchange but does not directly promote airway clearance. Instructing the patient on the pursed lip breathing technique is beneficial for improving gas exchange in patients with COPD but does not directly aid in airway clearance in a patient with bacterial pneumonia and thick sputum.