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 asks nurse Carlos the rationale for giving multi-drug treatment for tuberculosis. Which is an appropriate response?
- A. multiple drugs allow reduced levels of drugs to be given
- B. multiple drugs reduce undesirable drug side-effect
- C. multiple drugs potentiate the action fo the drugs
- D. multiple drugs reduce development of resistant strains of the bacteria
Correct Answer: D
Rationale: The correct answer is D because using multiple drugs for tuberculosis reduces the development of resistant strains of the bacteria. When multiple drugs are used simultaneously, it decreases the likelihood of the bacteria developing resistance to any single drug. This approach helps to ensure that the treatment remains effective over time.
Explanation for other choices:
A: While using multiple drugs may allow for reduced dosages, the primary rationale is not solely to administer lower levels of drugs.
B: Although using multiple drugs may help in managing side effects, the primary rationale is to prevent the development of resistant strains.
C: While multiple drugs may have a synergistic effect, the main purpose is to prevent resistance rather than potentiate the action of individual drugs.
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.
Approximately how much fluid is lost in acute weight loss of .5kg?
- A. 50 ml
- B. 750 ml
- C. 500 ml
- D. 75 ml
Correct Answer: C
Rationale: The correct answer is C: 500 ml. When someone loses 0.5 kg of weight, it is estimated that about 500 ml of fluid has been lost, as 1 kg of body weight is roughly equivalent to 1 liter of fluid. This fluid loss is due to water loss through sweating, breathing, and urine. Choice A (50 ml) is too small of an amount for a significant weight loss. Choice B (750 ml) is too high and would correspond to a larger weight loss. Choice D (75 ml) is also too small to account for a 0.5 kg weight loss.
Which of the following outcomes is correctly written?
- A. Abdominal incision will show no signs of infection.
- B. On discharge, client will be free of infection.
- C. On discharge, client will be able to list five symptoms of infection.
- D. During home care, nurse will not observe symptoms of infection.
Correct Answer: C
Rationale: The correct answer is C because it clearly states a measurable outcome by specifying that the client will be able to list five symptoms of infection. This outcome is specific, measurable, achievable, relevant, and time-bound (SMART). Choice A lacks specificity and measurability. Choice B is vague and does not provide a quantifiable measure of success. Choice D does not specify who will be observing the symptoms or how they will be documented. Overall, choice C stands out as the most appropriate outcome as it is clear, achievable, and directly related to assessing the client's understanding of infection symptoms.
Why should the nurse wake up a client who is to undergo an EEG at midnight?
- A. Because excess sleep may make the client lazy and nervous for the EEG
- B. Because optimum sleep helps regulate the breathing patterns during the EEG
- C. Because it helps the client to fall asleep naturally during the EEG
- D. Because it reduces the chances of getting a headache when electrodes are fixed to the scalp of the client
Correct Answer: B
Rationale: The correct answer is B because optimum sleep helps regulate breathing patterns during an EEG. Waking the client at midnight allows them to have a full night's rest, ensuring they are well-rested and their breathing is stable for accurate EEG results. Choice A is incorrect as excess sleep does not affect nervousness. Choice C is incorrect as waking the client does not help them fall asleep naturally during the EEG. Choice D is incorrect as headache prevention is not directly related to waking the client at midnight.