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The nurse in the medical ICU is caring for a patient who is in respiratory acidosis due to inadequate ventilation.
What diagnosis could the patient have that could cause inadequate ventilation?
- A. Endocarditis
- B. Multiple myeloma
- C. Guillain-Barr syndrome
- D. Overdose of amphetamines
Correct Answer: C
Rationale: Rationale: Guillain-Barr syndrome can cause inadequate ventilation due to paralysis of the respiratory muscles. This results in respiratory acidosis. Endocarditis, multiple myeloma, and amphetamine overdose do not directly affect ventilation. Endocarditis is an infection of the heart valves, multiple myeloma is a cancer of plasma cells, and amphetamine overdose primarily affects the central nervous system and cardiovascular system, not ventilation. Therefore, Guillain-Barr syndrome is the most likely diagnosis in this case.
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You are the nurse caring for a patient who is to receive IV daunorubicin, a chemotherapeutic agent. You start the
infusion and check the insertion site as per protocol. During your most recent check, you note that the IV has infiltrated
so you stop the infusion. What is your main concern with this infiltration?
- A. Extravasation of the medication
- B. Discomfort to the patient
- C. Blanching at the site
- D. Hypersensitivity reaction to the medication
Correct Answer: A
Rationale: The correct answer is A: Extravasation of the medication. Extravasation occurs when the infused medication leaks into surrounding tissues, potentially causing tissue damage and necrosis. This is a serious concern with vesicant medications like daunorubicin. If left untreated, it can lead to severe complications.
Choice B: Discomfort to the patient is incorrect because while discomfort may occur with infiltration, the main concern is the potential for tissue damage from extravasation.
Choice C: Blanching at the site is incorrect as it is a common sign of infiltration, but the main concern is the possibility of extravasation and tissue damage.
Choice D: Hypersensitivity reaction to the medication is incorrect as it is a different type of reaction that is not directly related to infiltration or extravasation.
. A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in
renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability?
- A. The kidneys regulate and reabsorb carbonic acid to change and maintain pH.
- B. The kidneys buffer acids through electrolyte changes
- C. The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
- D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.
Correct Answer: C
Rationale: Rationale:
C is correct because in renal failure, the kidneys lose the ability to regenerate and reabsorb bicarbonate, which is essential for maintaining a stable pH level in the body. B is incorrect because the kidneys primarily regulate pH by controlling bicarbonate levels, not through electrolyte changes. A is incorrect because the kidneys do not regulate carbonic acid in the same way. D is incorrect as it does not accurately describe the process of pH regulation in the kidneys.
After administering 40 mEq of potassium chloride, a nurse evaluates the clients response. Which manifestations indicate that treatment is improving the clients hypokalemia? (Select all tha do not t apply.)
- A. Strong productive cough
- B. Active bowel sounds
- C. U waves present on the electrocardiogram (ECG)
Correct Answer: C
Rationale: The correct answer is C: U waves present on the electrocardiogram (ECG). U waves are indicative of hypokalemia, and their presence indicates that the potassium chloride treatment is improving the condition.
Explanation:
1. A: Strong productive cough - This manifestation is not related to potassium levels and does not indicate improvement in hypokalemia.
2. B: Active bowel sounds - While hypokalemia can cause gastrointestinal issues, active bowel sounds alone do not specifically indicate improvement in potassium levels.
3. C: U waves present on ECG - U waves are a classic ECG finding in hypokalemia. The presence of U waves indicates a positive response to potassium chloride treatment.
4. D: No response provided - Not applicable.
In summary, the presence of U waves on the ECG is a key indicator of improvement in hypokalemia, while the other manifestations do not directly relate to potassium levels.
A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
- A. Assess the airway.
- B. Administer prescribed bronchodilators.
- C. Provide oxygen.
- D. Administer prescribed mucolytics
Correct Answer: A
Rationale: The correct answer is A: Assess the airway. The nurse should prioritize airway assessment as the client's ABGs indicate respiratory acidosis (low pH, high PaCO2). This suggests potential airway obstruction or inadequate ventilation. Ensuring a patent airway is crucial for adequate oxygenation. Administering bronchodilators (B) or mucolytics (D) may help with airway clearance but should come after ensuring a clear airway. Providing oxygen (C) is important, but addressing the underlying respiratory acidosis by first assessing the airway is the priority in this situation to prevent further deterioration.
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical manifestations are correctly paired with the contributing electrolyte imbalance? (Select all that do not apply.)
- A. Hypokalemia Flaccid paralysis with respiratory depression
- B. Hyperphosphatemia Paresthesia with sensations of tingling and numbness
- C. . Hyponatremia Decreased level of consciousness
Correct Answer: B
Rationale: The correct answer is B because hyperphosphatemia can lead to paresthesia with sensations of tingling and numbness due to its effect on nerve function.
A, hypokalemia causes muscle weakness but not flaccid paralysis with respiratory depression.
C, hyponatremia typically presents with symptoms such as confusion and seizures, not decreased level of consciousness.