Nokea
The nurse is teaching a class on acid-base imbalances. It would be correct for the nurse to identify which of the following would cause respiratory acidosis? Select all that apply.
- A. Aspirin overdose
- B. Pneumothorax
- C. Opioid overdose
- D. Anxiety
- E. Renal disease
Correct Answer: B,C
Rationale: Pneumothorax and opioid overdose impair ventilation, causing CO2 retention and respiratory acidosis.
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The nurse is assessing a client who was admitted four hours ago with hypomagnesemia. Which of the following findings should the nurse recognize as a common cause of hypomagnesemia? Select all that apply.
- A. Renal failure
- B. Alcoholism
- C. Anorexia nervosa
- D. Diarrhea
- E. Hypothyroidism
Correct Answer: B,C,D
Rationale: Alcoholism, anorexia nervosa, and diarrhea cause magnesium loss through malnutrition, malabsorption, or gastrointestinal losses.
When assessing for dehydration, the nurse should observe for which of the following?
- A. Headache and increased urinary output
- B. Weight gain and edema
- C. Hypertension and decreased urinary output
- D. Hypotension, headache, and dry mucous membranes
Correct Answer: D
Rationale: Dehydration causes hypotension, headache, and dry mucous membranes due to fluid loss.
The nurse is caring for a client in the medical-surgical unit. The nurse is reviewing the client's laboratory data and should take which action.
- A. Review the client's current medications
- B. Plan to initiate daily fluid restrictions
- C. Clarify the prescribed chest radiograph (x-ray)
- D. Insert an indwelling urinary catheter to monitor urinary output
Correct Answer: A
Rationale: Reviewing medications identifies potential causes of lab abnormalities, guiding appropriate interventions.
Following surgery for a prolapsed bladder, a 74-year-old female client is two days postoperative with an indwelling urinary catheter. While the nurse is making morning rounds, the client states, 'I feel like peeing again!' The most appropriate response for the nurse is:
- A. It's just bladder spasms. Nothing to worry about.'
- B. Let me look at your urine bag to ensure it's draining properly.'
- C. You should do Kegel exercises regularly to stop this urge to void.'
- D. Is this the first time this has happened?'
Correct Answer: B
Rationale: Checking the urine bag ensures the catheter is draining properly, addressing the sensation of needing to urinate.
The following scenario applies to the next 1 items
The student nurse is assisting the nurse in caring for a 31-year-old female in the outpatient clinic.
Item 1 of 1
Nurses' Note
1415: The client requested her annual physical be moved up because of urinary symptoms that started nine months ago. She states that she has managed so far with them, but she is starting a new traveling job and would like to get any necessary treatment. She states that every time she laughs or sneezes, she leaks a small amount of urine. She reports that this also occurs while performing intense physical exercise. The symptoms occur daily. She denies increased frequency, urgency, and burning upon urination. She denies having any vaginal discharge. She was treated for a urinary tract infection two months ago with antibiotics.
Diagnostic Results
1500:
Bladder scan - post-void residual
20 mL
Medical History
• Chronic low back pain following a motor vehicle crash
• Obstetric history - G = 2, T = 2 (vaginal deliveries), P = 0, A = 0, L = 2
The nurse reviews the concept of urinary incontinence, its causes, and symptoms with the student nurse. Click to specify if the causes or symptoms are consistent with the disease process of stress incontinence, overflow incontinence, or urge incontinence.
- A. Urine loss with physical exertion, cough, sneeze, or exercise
- B. Palpable bladder during assessment
- C. Caused by neurologic disorders, such as multiple sclerosis or spinal cord damage
- D. Caused by vaginal prolapse from vaginal birth or aging
- E. Caused by bladder irritants, such as artificial sweeteners, caffeine, alcohol
- F. Caused by constipation
- G. Loss of large amounts of urine with each occurrence
Correct Answer: A: Stress incontinence, B: Overflow incontinence, C: Urge incontinence, D: Stress incontinence, E: Urge incontinence, F: Overflow incontinence, G: Overflow incontinence
Rationale: Stress incontinence involves urine loss with exertion. Overflow incontinence is associated with palpable bladder, constipation, and large urine loss. Urge incontinence is linked to neurologic disorders and bladder irritants.