Nokea
A patient has chronic respiratory acidosis related to long-standing lung disease. Which of the following problems is the cause?
- A. Hyperventilation
- B. Loss of acid by kidneys
- C. Hypoventilation
- D. Loss of base by kidneys CARING FOR CLIENTS REQUIRING INTRAVENOUS THERAPY
Correct Answer: C
Rationale: The correct answer is C: Hypoventilation. In chronic respiratory acidosis, the lungs cannot effectively eliminate carbon dioxide, leading to an accumulation of CO2 in the blood, causing acidosis. Hypoventilation results in decreased removal of CO2, exacerbating the acidosis.
A: Hyperventilation would lead to respiratory alkalosis, not acidosis.
B: Loss of acid by kidneys would result in metabolic alkalosis, not respiratory acidosis.
D: Loss of base by kidneys would lead to metabolic acidosis, not respiratory acidosis.
In summary, the main issue in chronic respiratory acidosis is inadequate elimination of CO2 due to hypoventilation, leading to acidosis.
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A client tells the nurse that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:
- A. Urine glucose level
- B. Serum fructosamine level
- C. Fasting blood glucose level
- D. Glycosylated hemoglobin level
Correct Answer: D
Rationale: The correct answer is D: Glycosylated hemoglobin level. This test provides an average blood glucose level over the past 2-3 months, reflecting long-term glycemic control. It is a more reliable indicator compared to other options. A: Urine glucose level only shows current glucose levels and is not a reliable indicator of long-term control. B: Serum fructosamine level reflects blood glucose control over the past 2-3 weeks, not the 3-month period the client has been making efforts. C: Fasting blood glucose level gives a snapshot of the current glucose level, not long-term control like glycosylated hemoglobin does.
Which action should the nurse take first during the initial phase of implementation?
- A. Determine patient outcomes and goals.
- B. Prioritize patient’s nursing diagnoses.
- C. Evaluate interventions.
- D. Reassess the patient.
Correct Answer: D
Rationale: The correct answer is D: Reassess the patient. During the initial phase of implementation, the nurse should first reassess the patient to gather current data and evaluate the effectiveness of previous interventions. This step ensures that the nurse has updated information to make informed decisions about the patient's care. A: Determining patient outcomes and goals should come after reassessment. B: Prioritizing nursing diagnoses is important but should be based on current assessment data. C: Evaluating interventions should be done after implementing them and giving them time to take effect.
At a public health fair, the nurse teaches a group of women about breast cancer awareness. Possible signs of breast cancer include:
- A. Fever.
- B. Nipple discharge and a breast nodule.
- C. Breast changes during menstruation.
- D. Fever and erythema of the breast.
Correct Answer: B
Rationale: The correct answer is B because nipple discharge and a breast nodule are classic signs of breast cancer. Nipple discharge can be bloody or clear, and a breast nodule is a lump that feels different from the surrounding tissue. Fever (choice A) is not a common sign of breast cancer. Breast changes during menstruation (choice C) are normal hormonal fluctuations. Fever and erythema of the breast (choice D) are more indicative of an infection rather than breast cancer. Therefore, choice B is the most relevant sign of breast cancer among the options provided.
Which blood product replaces missing clotting factors in the patient who has a bleeding disorder?
- A. Platelets
- B. Albumin
- C. Packed RBC
- D. Cryoprecipitate
Correct Answer: D
Rationale: The correct answer is D: Cryoprecipitate. Cryoprecipitate contains high levels of clotting factors such as fibrinogen, Factor VIII, Factor XIII, and von Willebrand factor, making it the ideal choice to replace missing clotting factors in patients with bleeding disorders. Platelets (A) help with clot formation but do not contain clotting factors. Albumin (B) is a protein used for volume replacement, not clotting factor replacement. Packed RBC (C) is used to increase oxygen-carrying capacity in anemic patients, not for clotting factor replacement.
An adult has been stung by a bee and is in anaphylactic shock. An epinephrine (adrenaline) injection has been given. The nurse would expect which the following if the injection has been effective?
- A. The client’s breathing will become easier
- B. The client’s blood pressure will decrease
- C. There will be an increase in angiodema
- D. There will be a decrease in the client’s level of consciousness
Correct Answer: A
Rationale: The correct answer is A: The client’s breathing will become easier. Epinephrine is the first-line treatment for anaphylaxis as it helps to reverse the severe respiratory symptoms. By administering epinephrine, it causes bronchodilation, which helps improve breathing by opening up the airways. Choices B, C, and D are incorrect. B is incorrect because epinephrine typically causes an increase in blood pressure due to its vasoconstrictive effects. C is incorrect because angioedema is a potential side effect of anaphylaxis and would not be expected to increase after epinephrine administration. D is incorrect because epinephrine helps to improve alertness and consciousness by increasing blood flow to the brain.