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A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, the lungs are unable to eliminate enough carbon dioxide, leading to an increase in CO2 levels in the blood, causing acidosis. This is due to inadequate ventilation or impaired gas exchange. The other options are incorrect because: B) Loss of bicarbonate is seen in metabolic acidosis, not respiratory acidosis. C) Excessive vomiting leads to metabolic alkalosis, not respiratory acidosis. D) Hyperventilation would actually correct respiratory acidosis by decreasing CO2 levels.
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A nurse is preparing a teaching plan for a client who is starting to receive hemodialysis for chronic kidney disease. Which of the following instructions should the nurse include in the teaching?
- A. Increase your intake of protein to 1 to 1.5 grams per kilogram per day.
- B. Reduce your fluid intake to 1L per day.
- C. Increase sodium intake to prevent hypotension.
- D. Monitor blood glucose levels daily.
Correct Answer: A
Rationale: The correct answer is A: Increase your intake of protein to 1 to 1.5 grams per kilogram per day. This is because patients undergoing hemodialysis often experience protein loss during the process. Adequate protein intake helps maintain muscle mass and supports overall health. Option B is incorrect as fluid restriction is typically recommended for patients on hemodialysis due to impaired fluid removal by the kidneys. Option C is incorrect as increasing sodium intake can lead to fluid retention and exacerbate hypertension, a common complication in chronic kidney disease. Option D is not directly related to hemodialysis and is more pertinent to diabetes management.
A nurse is caring for a client who has chronic venous insufficiency. Which of the following areas should the nurse assess for the presence of a venous ulcer?
- A. Tip of the toes
- B. Medial malleolus (ankle)
- C. Ball of the foot
- D. Heel of the foot
Correct Answer: B
Rationale: The correct answer is B: Medial malleolus (ankle). Venous ulcers commonly occur in areas where there is poor circulation, such as the lower legs. The medial malleolus is a common site for venous ulcers in individuals with chronic venous insufficiency due to pooling of blood in the lower extremities. Assessing this area is crucial for early detection and appropriate management. Choices A, C, and D are incorrect as venous ulcers typically develop in areas with high venous pressure and poor circulation, such as the lower legs, not at the tip of the toes, ball of the foot, or heel.
A nurse is caring for a male client who has a new prescription for cyclosporine following a kidney transplant. Which of the following findings should the nurse identify as an adverse effect of this therapy?
- A. BUN 24 mg/dL
- B. Blood glucose 95 mg/dL
- C. Platelets 250
- D. 000/mm³
- E. Hemoglobin 14 g/Dl
Correct Answer: A
Rationale: The correct answer is A: BUN 24 mg/dL. Cyclosporine, an immunosuppressant medication, can cause nephrotoxicity as an adverse effect. An elevated BUN level indicates impaired kidney function, which can be a consequence of cyclosporine therapy. Blood glucose level (choice B) and platelet count (choice C) are not typically affected by cyclosporine. Hemoglobin level (choice E) is not directly related to cyclosporine therapy. Therefore, the nurse should be vigilant for signs of nephrotoxicity by monitoring the client's BUN level.
A nurse is providing discharge teaching to a client following a loop electrosurgical excision procedure (LEEP) for the treatment of cervical cancer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should expect heavy bleeding for the next week.
- B. I will avoid using tampons for the next few weeks.
- C. I should resume sexual activity within 24 hours.
- D. I will avoid all physical activity for a month.
Correct Answer: B
Rationale: The correct answer is B: "I will avoid using tampons for the next few weeks." This statement indicates an understanding of the discharge teaching because using tampons can introduce bacteria into the healing cervix, increasing the risk of infection post-LEEP. Choosing this answer demonstrates knowledge of the importance of maintaining good hygiene and minimizing infection risk during the healing process.
Other choices are incorrect:
A: Expecting heavy bleeding for the next week is incorrect as heavy bleeding should decrease gradually.
C: Resuming sexual activity within 24 hours is incorrect as it can increase the risk of infection and disrupt the healing process.
D: Avoiding all physical activity for a month is incorrect as light activities are usually allowed, and complete inactivity can lead to complications like blood clots.
A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?
- A. The client has decreased mucus production.
- B. The clients daily peak expiratory flow (PEF) measures 85% above personal best.
- C. The client has a respiratory rate of 24/min.
- D. The client reports no nighttime coughing.
Correct Answer: B
Rationale: The correct answer is B because an increase in the client's daily peak expiratory flow (PEF) by 85% above their personal best indicates improved lung function, which is a positive response to salmeterol. This demonstrates that the medication is effectively managing the asthma symptoms.
Choice A is incorrect because decreased mucus production is not a direct indicator of salmeterol's effectiveness in treating asthma. Choice C is incorrect as the respiratory rate alone does not provide specific information about the medication's effectiveness. Choice D is incorrect since the absence of nighttime coughing may be due to various factors and not solely because of salmeterol's effectiveness.