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A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect?
- A. Cyanosis
- B. Agitation
- C. Hypotension
- D. Dizziness
Correct Answer: B
Rationale: The correct answer is B: Agitation. During an asthma attack, hypoxemia can lead to decreased oxygen supply to the brain, causing agitation due to hypoxia. Cyanosis (A) is a bluish discoloration of the skin and mucous membranes, indicating severe hypoxemia. Hypotension (C) is not typically associated with hypoxemia in asthma. Dizziness (D) is more commonly seen in conditions like hyperventilation rather than hypoxemia. In summary, agitation is the most likely manifestation of hypoxemia during an asthma attack due to decreased oxygen supply to the brain.
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A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?
- A. Basal cell carcinoma has a low incidence of metastasis.
- B. Basal cell carcinoma is often fatal.
- C. Basal cell carcinoma metastasizes early.
- D. Basal cell carcinoma is more common in younger clients.
Correct Answer: A
Rationale: The correct answer is A: Basal cell carcinoma has a low incidence of metastasis. Basal cell carcinoma rarely metastasizes to other parts of the body, making it highly curable through surgical excision. This information is crucial for patients to understand the low likelihood of the cancer spreading. Choices B and C are incorrect because basal cell carcinoma is not typically fatal nor does it metastasize early. Choice D is incorrect as basal cell carcinoma is more common in older adults, not younger clients.
A nurse is caring for a client who reports a new onset of severe chest pain. Which of the following actions should the nurse take to determine if the client is experiencing a myocardial infarction?
- A. Perform a 12-lead ECG
- B. Administer nitroglycerin
- C. Place the client in a prone position
- D. Assess the client's blood pressure
Correct Answer: A
Rationale: The correct answer is A: Perform a 12-lead ECG. This is because an ECG is the most reliable and direct way to assess for myocardial infarction by identifying characteristic changes in the heart's electrical activity. Nitroglycerin (B) is used to relieve chest pain but should not be administered before confirming the diagnosis. Placing the client in a prone position (C) is not appropriate for assessing chest pain. Assessing blood pressure (D) is important but not the initial priority when suspecting myocardial infarction.
A nurse is planning an educational program about basal cell carcinoma. Which of the following information should the nurse plan to include?
- A. Basal cell carcinoma has a low incidence of metastasis.
- B. Basal cell carcinoma often spreads to lymph nodes.
- C. Basal cell carcinoma is most common in young adults.
- D. Basal cell carcinoma is curable with chemotherapy.
Correct Answer: A
Rationale: The correct answer is A: Basal cell carcinoma has a low incidence of metastasis. This should be included in the educational program because basal cell carcinoma rarely metastasizes. Metastasis is the spread of cancer from the original site to other parts of the body, and in the case of basal cell carcinoma, it tends to remain localized. This information is crucial for patients to understand the prognosis and treatment options.
Explanation of why other choices are incorrect:
B: Basal cell carcinoma often spreads to lymph nodes - This statement is incorrect as basal cell carcinoma typically does not spread to lymph nodes.
C: Basal cell carcinoma is most common in young adults - Basal cell carcinoma is more common in older individuals, typically over the age of 50.
D: Basal cell carcinoma is curable with chemotherapy - While chemotherapy may be a treatment option for some cases of basal cell carcinoma, it is not the primary treatment and not always curative.
A nurse cares for a client on ethambutol therapy for tuberculosis. What should be monitored?
- A. Hearing loss
- B. Visual acuity
- C. Liver function
- D. Blood glucose
Correct Answer: B
Rationale: The correct answer is B: Visual acuity. Ethambutol can cause optic neuritis, leading to visual disturbances. Monitoring visual acuity is crucial to detect any changes early.
Incorrect choices:
A: Hearing loss is associated with other medications for TB, not ethambutol.
C: Liver function is not typically affected by ethambutol.
D: Blood glucose is not directly impacted by ethambutol therapy.
In summary, monitoring visual acuity is essential due to the potential optic nerve toxicity of ethambutol, making it the most relevant parameter to monitor in this case.
A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
- A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
- B. pH 7.40, HCO3- 24 mEq/L, PaCO2 38 mm Hg
- C. pH 7.45, HCO3- 28 mEq/L, PaCO2 40 mm Hg
- D. pH 7.50, HCO3- 30 mEq/L, PaCO2 45 mm Hg
Correct Answer: A
Rationale: The correct answer is A (pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg). In chronic kidney disease, the kidneys are unable to excrete acid effectively, leading to metabolic acidosis. The pH is low (acidotic) due to the accumulation of acids. The bicarbonate (HCO3-) is low (19 mEq/L) as the kidneys are unable to reabsorb and regenerate bicarbonate effectively. The PaCO2 is low (30 mm Hg) as the respiratory system compensates by increasing the respiratory rate to blow off carbon dioxide in an attempt to normalize the pH. Choices B, C, and D have pH values within normal range and do not reflect the expected acidosis in chronic kidney disease.