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Mr. N is a client who entered the hospital with a diagnosis of diabetic ketoacidosis. The nurse enters his room to check his vital signs and finds him breathing at a rate of 32 times per minute; his respirations are deep and regular. Which type of respiratory pattern is Mr. N most likely exhibiting?
- A. Kussmaul respirations
- B. Cheyne-Stokes respirations
- C. Biot's respirations
- D. Cluster breathing
Correct Answer: A
Rationale: Mr. N is exhibiting Kussmaul respirations, characterized by rapid, deep, and regular breathing. This type of respiratory pattern is commonly seen in metabolic acidosis, such as in diabetic ketoacidosis. Kussmaul respirations are a form of hyperventilation, leading to the elimination of carbon dioxide from the body. Choice B, Cheyne-Stokes respirations, is characterized by alternating periods of deep, rapid breathing followed by periods of apnea and is not typically associated with diabetic ketoacidosis. Choice C, Biot's respirations, involve irregular breathing patterns with periods of apnea and are not reflective of the described breathing pattern. Cluster breathing, as mentioned in Choice D, is not a recognized term in respiratory patterns and does not describe the breathing pattern observed in Mr. N.
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The nurse has taught a client with a below-the-knee amputation about home care and about monitoring for and preventing complications related to prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client stated that which action should be taken?
- A. Wear a clean nylon sock over the residual limb every day.
- B. Use a mirror to inspect all areas of the residual limb each day.
- C. Toughen the skin of the residual limb by rubbing it with alcohol.
- D. Prevent cracking of the skin of the residual limb by applying lotion daily.
Correct Answer: B
Rationale: The client should inspect all surfaces of the residual limb daily for irritation, blisters, and breakdown. The client should wear a clean woolen (not nylon) sock each day. The residual limb is cleansed daily with a gentle soap and water and dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils and creams are also avoided because they are too softening to the skin for safe prosthesis use.
The nurse provides home care instructions to a client diagnosed with cancer who has an implanted vascular access port. Which statement by the client indicates the need for further teaching?
- A. I should keep the site clean and dry.
- B. If the site becomes red, I will notify my doctor.
- C. I should pump the port daily to maintain patency.
- D. The port will need to be flushed with saline to maintain patency.
Correct Answer: C
Rationale: Implanted vascular access ports do not require daily pumping to maintain patency; this is incorrect. Keeping the site clean and dry, notifying the doctor about redness, and flushing with saline (or heparin, per agency protocol) are correct care measures.
A 58-year-old client is being tested for rheumatoid arthritis. Her physician orders an erythrocyte sedimentation rate (ESR). Which of the following results is most likely to be associated with arthritis?
- A. 5 mm/hr
- B. 12 mm/hr
- C. 28 mm/hr
- D. 40 mm/hr
Correct Answer: D
Rationale: The erythrocyte sedimentation rate (ESR) measures levels of inflammation in the body. Elevated ESR levels are commonly seen in autoimmune conditions like rheumatoid arthritis due to the presence of inflammation. In women over 50 years old, a normal ESR is typically below 30 mm/hr. Therefore, a result of 40 mm/hr is more indicative of arthritis in a 58-year-old individual. Choices A, B, and C are below the normal ESR range for a woman of this age and would not be as strongly associated with arthritis.
The nurse is providing home care instructions to a client recovering from an acute inferior myocardial infarction (MI) with recurrent angina. What instruction should the nurse provide to this client?
- A. Avoid sexual intercourse for at least 4 months.
- B. Replace sublingual nitroglycerin tablets yearly.
- C. Participate in an exercise program that includes overhead lifting and reaching.
- D. Recognize the adverse effects of acetylsalicylic acid (aspirin), which include tinnitus and hearing loss.
Correct Answer: D
Rationale: After an acute MI, many clients are instructed to take an aspirin daily. Adverse effects include tinnitus, hearing loss, epigastric distress, gastrointestinal bleeding, and nausea. Sexual intercourse usually can be resumed in 4 to 8 weeks after an acute MI if the primary health care provider agrees and if the client has been able to achieve traditional parameters such as climbing two flights of steps without chest pain or dyspnea. Clients should be advised to purchase a new supply of nitroglycerin tablets every 6 months. Expiration dates on the medication bottle should also be checked. Activities that include lifting and reaching over the head should be avoided because they reduce cardiac output.
The nurse is instructing a pregnant client regarding measures to prevent a recurrent episode of preterm labor. Which statement by the client indicates the need for further teaching?
- A. I will report any feeling of pelvic pressure.
- B. I will not engage in sexual intercourse at this time.
- C. I will adhere to the limitations in activity and stay off my feet.
- D. I will limit my fluid intake to three 8-ounce glasses of fluid per day.
Correct Answer: D
Rationale: Risks for preterm labor include dehydration. A client should not restrict fluids (except for those containing alcohol and caffeine). A sign of preterm labor may be pelvic pressure without the perception of a contraction. Mechanical stimulation of the cervix during intercourse can stimulate contractions. A decrease in activity and bed rest are often prescribed in an attempt to decrease pressure on the cervix and to increase uterine blood flow.