Nokea
The nurse is caring for a client diagnosed with diabetic ketoacidosis (DKA). Which statement best explains the scientific rationale for the client’s Kussmaul’s respirations?
- A. The kidneys produce excess urine and the lungs try to compensate.
- B. The respirations increase the amount of carbon dioxide in the bloodstream.
- C. The lungs speed up to release carbon dioxide and increase the pH.
- D. The shallow and slow respirations will increase the HCO3 in the serum.
Correct Answer: C
Rationale: Kussmaul’s respirations (rapid, deep breathing) in DKA compensate for metabolic acidosis by excreting carbon dioxide, a volatile acid, to raise blood pH. Kidneys excrete acid, not urine, and respirations do not increase CO2 or HCO3.
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Which clinical manifestations should the nurse expect to assess for the client diagnosed with a ureteral renal stone?
- A. Dull, aching flank pain and microscopic hematuria.
- B. Nausea; vomiting; pallor; and cool, clammy skin.
- C. Gross hematuria and dull suprapubic pain with voiding.
- D. The client will be asymptomatic.
Correct Answer: B
Rationale: Ureteral stones cause severe colicky pain, often with nausea, vomiting, pallor, and diaphoresis due to autonomic response. Flank pain and microscopic hematuria are more typical of renal pelvic stones, gross hematuria is less common, and stones are rarely asymptomatic.
In evaluating multiple clients with UTIs, the clinic nurse should identify which client to be at least risk for developing a UTI?
- A. A client with urethral mucosa damage
- B. A client with an altered mental condition
- C. A client with an altered metabolic state
- D. An immunocompromised client
Correct Answer: C
Rationale: An altered metabolic state, without specific risk factors like diabetes, poses the least risk for UTIs compared to mucosal damage, mental status changes, or immunosuppression.
The clinic nurse is caring for a client diagnosed with chronic pyelonephritis who is prescribed trimethoprim-sulfamethoxazole (Bactrim), a sulfa antibiotic, twice a day for 90 days. Which statement is the scientific rationale for prescribing this medication?
- A. The antibiotic will treat the bladder spasms that accompany a urinary tract infection.
- B. If the urine cannot be made bacteria free, the Bactrim will suppress bacterial growth.
- C. In three (3) months, the client should be rid of all bacteria in the urinary tract.
- D. The HCP is providing the client with enough medication to treat future infections.
Correct Answer: B
Rationale: Chronic pyelonephritis often requires long-term antibiotics like Bactrim to suppress bacterial growth when complete eradication is not possible. It does not treat spasms, and 90 days may not eliminate all bacteria or be for future use.
While the fluid is being administered, which nursing assessment is most important?
- A. Checking for pedal edema
- B. Assessing the rapid weight gain
- C. Monitoring specific gravity
- D. Auscultating breath sounds
Correct Answer: D
Rationale: Auscultating breath sounds is critical during a fluid challenge to detect signs of fluid overload, such as pulmonary edema.
The elderly client being seen in the clinic has complaints of urinary frequency, urgency, and 'leaking.' Which priority intervention should the nurse implement when interviewing the client?
- A. Ensure communication is nonjudgmental and respectful.
- B. Set the temperature for comfort in the examination room.
- C. Speak loudly to ensure the client understands the nurse.
- D. Ensure the examining room has adequate lighting.
Correct Answer: A
Rationale: Nonjudgmental, respectful communication builds trust, encouraging the elderly client to discuss sensitive incontinence issues openly. Comfort, loud speech, and lighting are secondary to effective communication.