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A nurse is assessing a client who has Cushings syndrome. Which of the following findings should the nurse expect?
- A. Osteoporosis
- B. Hypertension
- C. Weight loss
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Osteoporosis. In Cushing's syndrome, excess cortisol weakens bones, leading to osteoporosis. B: Hypertension is common in Cushing's due to cortisol's effects on blood vessels. C: Weight gain, not loss, is typically seen in Cushing's due to cortisol-induced fat redistribution. D: Hyperglycemia, not hypoglycemia, is common due to cortisol's role in glucose metabolism. E, F, G are irrelevant. In summary, osteoporosis is expected due to cortisol's impact on bone health, while the other options are not typical findings in Cushing's syndrome.
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A nurse is caring for a client who has acute kidney injury and a potassium level of 6.5 mEq/L. Which of the following ECG changes should the nurse expect?
- A. Flattened T waves
- B. Peaked T waves
- C. Prolonged PR interval
- D. ST segment depression
Correct Answer: B
Rationale: The correct answer is B: Peaked T waves. In hyperkalemia (high potassium level), the myocardium becomes more excitable, leading to changes in the ECG. Peaked T waves are a classic sign of hyperkalemia, indicating early stages of cardiac involvement. Flattened T waves (choice A) are associated with hypokalemia. Prolonged PR interval (choice C) and ST segment depression (choice D) are not typically seen in hyperkalemia.
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.
A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
- A. Red-tinged drainage on the dressing
- B. Cloudy urine in the catheter
- C. Clear drainage on the dressings
- D. Mild back pain at the surgical site
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice D) is common after this surgery and does not necessarily indicate a complication.
A nurse is planning care for a client who is scheduled for surgery and has a latex allergy. Which of the following actions should the nurse plan to take?
- A. Use only powder-free latex gloves.
- B. Place monitoring cords and tubes in a stockinette.
- C. Avoid using iodine-based antiseptics.
- D. Administer prophylactic antihistamines.
Correct Answer: B
Rationale: The correct answer is B: Place monitoring cords and tubes in a stockinette. This is important for the client with a latex allergy because stockinettes provide a barrier between the latex-containing materials and the client's skin, reducing the risk of allergic reactions. Using powder-free latex gloves (choice A) is a good practice, but it is not directly addressing the risk of exposure to latex for the client. Avoiding iodine-based antiseptics (choice C) is not necessary unless the client has a specific allergy to iodine. Administering prophylactic antihistamines (choice D) is not a standard practice for latex allergies and may not prevent an allergic reaction.
A nurse is planning care for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
- A. Standard precautions
- B. Airborne precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is spread through the air via droplet nuclei. Implementing airborne precautions involves placing the client in a negative pressure room, using an N95 respirator, and ensuring proper ventilation. Standard precautions (A) are used for all clients. Contact precautions (C) are used for clients with infections that can be spread by direct or indirect contact. Droplet precautions (D) are used for infections spread through larger respiratory droplets. In this case, airborne precautions are specifically needed due to the mode of transmission of tuberculosis.