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The nurse interprets this as?
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: The nurse interprets this as respiratory alkalosis because the patient is likely experiencing hyperventilation, leading to a decrease in CO2 levels and respiratory alkalosis. This is indicated by an increase in pH and a decrease in PaCO2 on arterial blood gas analysis. Metabolic acidosis (choice B) is characterized by low pH and low bicarbonate levels, not seen in this scenario. Respiratory acidosis (choice A) is characterized by high PaCO2 levels and low pH, which is not the case here. Metabolic alkalosis (choice D) is characterized by high pH and high bicarbonate levels, which is not consistent with the patient's presentation.
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Which interventions are appropriate for a patient with diabetes and poor wound healing? (Select all that apply.)
- A. Perform dressing changes twice a day as ordered.
- B. Teach the patient about signs and symptoms of infection.
- C. Instruct the family about how to perform dressing changes.
- D. Gently refocus patient from discussing body image changes.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Dressing changes twice a day help maintain a clean wound environment, reducing the risk of infection.
2. Regular dressing changes promote proper wound healing by facilitating moisture balance and removal of dead tissue.
3. It is a direct intervention that addresses the patient's poor wound healing.
4. Teaching the patient about signs of infection (B) is important but does not directly address the wound healing process.
5. Instructing the family on dressing changes (C) is helpful but should not substitute direct patient care.
6. Refocusing the patient from body image changes (D) is not directly related to improving wound healing.
Nurse Carlos teaches a community adult class about the common symptoms of tuberculosis. Which of the following should Nurse Carlos include?
- A. weight loss
- B. dyspnea on exertion
- C. increased appetite
- D. mental status changes
Correct Answer: A
Rationale: The correct answer is A: weight loss. Weight loss is a common symptom of tuberculosis due to the impact of the infection on the body's metabolism and appetite. This symptom is important to recognize as it can be an early indicator of the disease. Dyspnea on exertion (B) is not a common symptom of tuberculosis, as it typically affects the lungs rather than causing difficulty breathing. Increased appetite (C) is not a typical symptom, as TB usually leads to decreased appetite and weight loss. Mental status changes (D) are not directly associated with tuberculosis and are more commonly seen in other conditions affecting the brain. Therefore, weight loss is the most relevant symptom to include in the teaching material for identifying possible cases of tuberculosis.
A client is undergoing test for multiple myeloma. Diagnostic study findings in multiple Myeloma includes:
- A. A decreased serum creatinine level.
- B. Bence jones protein in the urine.
- C. Hypocalcemia.
- D. A low serum protein level.
Correct Answer: B
Rationale: The correct answer is B: Bence jones protein in the urine. In multiple myeloma, abnormal plasma cells produce excess monoclonal immunoglobulins, including Bence Jones proteins, which can be detected in the urine. This is a hallmark finding in multiple myeloma diagnosis.
A: Incorrect. Serum creatinine levels are typically not affected in multiple myeloma.
C: Incorrect. Hypercalcemia, not hypocalcemia, is commonly seen in multiple myeloma due to bone destruction.
D: Incorrect. Multiple myeloma often presents with high serum protein levels, not low levels.
Which of the ff. nursing interventions will help prevent complications in the patient with Bell’s Palsy?
- A. Megavitamin therapy
- B. Application of ice to the affected area
- C. Elastic bandages
- D. Lubricating eye drops
Correct Answer: D
Rationale: Correct Answer: D - Lubricating eye drops
Rationale: Lubricating eye drops help prevent complications such as corneal abrasions in patients with Bell's Palsy by keeping the eye moist and preventing dryness. Bell's Palsy can cause difficulty in closing the eye properly, leading to dryness and potential damage to the cornea. Using lubricating eye drops helps maintain eye health.
Summary of Incorrect Choices:
A: Megavitamin therapy - Not directly related to preventing complications in Bell's Palsy.
B: Application of ice to the affected area - Ice may not address eye dryness or prevent corneal abrasions.
C: Elastic bandages - Not relevant to preventing complications associated with Bell's Palsy.
The nurse is gathering data on a patient. Which data will the nurse report as objective data?
- A. States “doesn’t feel good”
- B. Reports a headache
- C. Respirations 16
- D. Nauseated
Correct Answer: C
Rationale: The correct answer is C because respirations of 16 are measurable and quantifiable, making them objective data. Subjective data, like choices A, B, and D, are based on the patient's feelings or experiences and cannot be measured or observed directly. Choice A is subjective as it relies on the patient's self-report. Choice B is subjective as it describes a symptom reported by the patient. Choice D is subjective as it reflects the patient's feeling of nausea. Objective data is essential for making accurate clinical assessments and decisions.