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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.
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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.
Place the following four nursing actions for the new laryngectomee in correct order of priority? i.Assist with ambulation ii.Set up a visit from a well-adjusted laryngectomee iii.Maintain a patent airway iv.Control postoperative pain
- A. 1, 2, 3, 4
- B. 3, 4, 1, 2
- C. 2, 3, 4, 1
- D. 4, 1, 2, 3
Correct Answer: C
Rationale: The correct order of priority for nursing actions for a new laryngectomee is: ii.Set up a visit from a well-adjusted laryngectomee, iii.Maintain a patent airway, iv.Control postoperative pain, i.Assist with ambulation. Setting up a visit from a well-adjusted laryngectomee comes first to provide emotional support and guidance. Maintaining a patent airway is crucial for breathing. Controlling postoperative pain is important for comfort. Assisting with ambulation is necessary but can be done after ensuring the other priorities are addressed. Other choices are incorrect because they do not prioritize emotional support, airway maintenance, and pain control before assisting with ambulation.
A client with a cerebellar brain tumor is admitted to an acute care facility. The nurse formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add to complete the nursing diagnosis statement?
- A. Related to visual field deficits
- B. Related to impaired balance
- C. Related to difficulty swallowing
- D. Related to psychomotor seizures
Correct Answer: B
Rationale: The correct answer is B: Related to impaired balance. The rationale for this is that a client with a cerebellar brain tumor may experience impaired balance due to the cerebellum's role in coordinating voluntary movements and maintaining balance. Impaired balance increases the risk for falls and other injuries. Visual field deficits, difficulty swallowing, and psychomotor seizures are not directly related to the cerebellum's functions in balance and coordination. Therefore, these choices are incorrect for this specific nursing diagnosis.
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.
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.