Nursing Elites

1. A client with a history of lung disease is at risk for respiratory acidosis. For which of the following signs and symptoms does the nurse assess this client?

• A. Disorientation and dyspnea
• B. Drowsiness, headache, and tachypnea
• C. Tachypnea, dizziness, and paresthesias
• D. Dysrhythmias and decreased respiratory rate and depth

Correct answer: A

Rationale: The correct answer is A: Disorientation and dyspnea. In respiratory acidosis, the retention of carbon dioxide leads to an increase in carbonic acid, causing the pH of the blood to decrease. This can result in symptoms such as dyspnea (difficulty breathing) due to hypoxia and disorientation due to the effects of hypercapnia (elevated carbon dioxide levels) on the brain. Choice B is incorrect because while drowsiness and tachypnea can be present in respiratory acidosis, headache is not a common symptom. Choice C is incorrect because dizziness and paresthesias are not typical symptoms of respiratory acidosis. Choice D is incorrect because dysrhythmias and a decreased respiratory rate and depth are more commonly associated with respiratory alkalosis, not respiratory acidosis.

2. A client with a diagnosis of hypothermia is being admitted to the hospital by a nurse. Which of the following signs does the nurse anticipate that this client will exhibit?

• A. Increased heart rate and increased blood pressure
• B. Increased heart rate and decreased blood pressure
• C. Decreased heart rate and increased blood pressure
• D. Decreased heart rate and decreased blood pressure

Correct answer: D

Rationale: Hypothermia decreases the heart rate and blood pressure due to reduced metabolic needs of the body. With lower metabolic demands, the heart's workload decreases, leading to reductions in both heart rate and blood pressure. Choices A, B, and C are incorrect because hypothermia typically results in a decrease in heart rate and blood pressure, not an increase.

3. A nurse cares for clients with urinary incontinence. Which types of incontinence are correctly paired with their clinical manifestations? (Select all that apply.)

• A. Stress incontinence – Urine loss with physical exertion
• B. Urge incontinence – Large amount of urine with each occurrence
• C. Overflow incontinence – Constant dribbling of urine
• D. All of the above

Correct answer: D

Rationale: The correct answer is D, as all the choices are correctly paired with their clinical manifestations. Stress incontinence is characterized by urine loss with physical exertion, coughing, sneezing, or exercising. Urge incontinence presents with a sudden and strong urge to void, often accompanied by a large amount of urine released during each occurrence. Overflow incontinence occurs when the bladder is distended, leading to a constant dribbling of urine. Functional incontinence, not mentioned in the options, is the leakage of urine due to factors unrelated to a lower urinary tract disorder. Reflex incontinence, also not mentioned, is a condition resulting from abnormal detrusor contractions.

4. During an assessment on a patient brought to the emergency department for treatment for dehydration, the nurse notes a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse observes cool, clammy skin. Which diagnosis does the nurse suspect?

• A. Fluid volume deficit (FVD)
• B. Fluid volume excess (FVE)
• C. Mild extracellular fluid (ECF) deficit
• D. Renal failure

Correct answer: A

Rationale: The nurse should suspect Fluid Volume Deficit (FVD) in this patient. Signs of FVD include elevated temperature, tachycardia, tachypnea, hypotension, orthostatic hypotension, and cool, clammy skin, which align with the patient's assessment findings. Choices B, C, and D are incorrect. Fluid Volume Excess (FVE) typically presents with bounding pulses, elevated blood pressure, dyspnea, and crackles. Mild extracellular fluid (ECF) deficit usually manifests as thirst. Renal failure commonly results in Fluid Volume Excess (FVE) rather than Fluid Volume Deficit (FVD).

5. After teaching a client with renal cancer who is prescribed temsirolimus (Torisel), the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the teaching?

• A. I will take this medication with food and plenty of water.
• B. I shall keep my appointment at the infusion center each week.
• C. I’ll limit my intake of green leafy vegetables while on this medication.
• D. I must not take this medication if I have an infection or am feeling ill.

Correct answer: B

Rationale: The correct answer is B. Temsirolimus, also known as Torisel, is administered as a weekly intravenous infusion. This medication blocks protein needed for cell division, inhibiting cell cycle progression. It is not taken orally, so there is no need to take it with food or water. Keeping the weekly infusion center appointment is crucial for the client to receive the prescribed treatment effectively. Choice A is incorrect as temsirolimus is not taken with food or water. Choice C is incorrect because there is no need to limit the intake of green leafy vegetables while on this medication. Choice D is incorrect as having an infection or feeling ill does not prohibit the use of temsirolimus.

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