Nokea
The nurse is assessing a 55-year-old client with chronic obstructive pulmonary disease. The client weighs 200 lb and is 6 feet tall. Using the diagram shown here, the nurse should record in the health history that the client's chest is:
- A. Barrel-shaped
- B. Muscular
- C. Normal for the client's age, height, and weight
- D. Showing the effects of long-term use of bronchodilators
Correct Answer: A
Rationale: A barrel-shaped chest is characteristic of chronic obstructive pulmonary disease due to hyperinflation of the lungs, which is likely in this client. The client's weight and height suggest a normal body habitus, not a muscular chest, and bronchodilator use does not directly cause this chest shape.
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A client with a history of anxiety disorder is prescribed buspirone (BuSpar). The nurse should explain that this medication:
- A. Works immediately to reduce anxiety.
- B. May take 2-4 weeks to achieve full effect.
- C. Should be taken with grapefruit juice.
- D. Is addictive and requires tapering.
Correct Answer: B
Rationale: Buspirone typically takes 2-4 weeks to achieve its full anti-anxiety effect, unlike benzodiazepines.
A client with the diagnosis of chronic kidney disease (CKD) has received dietary counseling about potassium restriction in the diet. The nurse determines that the client has learned the information correctly when the client states that he or she will do what when preparing vegetables?
- A. Eat only fresh vegetables.
- B. Boil them and discard the water.
- C. Use only salt substitutes to season.
- D. Buy frozen vegetables whenever possible.
Correct Answer: B
Rationale: The potassium content of vegetables can be reduced by boiling them and discarding the cooking water. Clients with CKD should avoid the use of salt substitutes altogether because they tend to be high in potassium content.
A client experiencing a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, PCO2 31 mm Hg, PaO2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. Respiratory alkalosis is present when the PCO2 is less than 35, whereas respiratory acidosis is present when the PCO2 is greater than 45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L, whereas metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L. This client's ABGs are consistent with respiratory alkalosis.
A primigravid client at 26 weeks' gestation asks the nurse what causes heartburn during pregnancy. The nurse should explain to the client that heartburn during pregnancy is usually caused by which of the following?
- A. Increased peristaltic action during pregnancy.
- B. Displacement of the stomach by the diaphragm.
- C. Decreased secretion of hydrochloric acid.
- D. Backflow of stomach contents into the esophagus.
Correct Answer: D
Rationale: Heartburn is caused when stomach contents enter the distal end of the esophagus, producing a burning sensation. To avoid heartburn during pregnancy, the client should avoid spicy foods; eat smaller, more frequent meals; and avoid lying down after eating. Peristalsis usually decreases during the latter half of pregnancy. Displacement of the stomach by the uterus, not the diaphragm, may contribute to heartburn. Increased, not decreased, secretion of hydrochloric acid can exacerbate heartburn.
A client is recovering from abdominal surgery and has a nasogastric (NG) tube inserted. The expected outcome of using the NG tube is gastrointestinal tract?
- A. Compression.
- B. Lavage.
- C. Decompression.
- D. Gavage.
Correct Answer: C
Rationale: An NG tube is used for decompression to remove air and fluid from the gastrointestinal tract post-surgery.