Nursing Elites

1. The nurse is providing discharge instructions to a client who is receiving prednisone 5 mg PO daily for a rash due to contact with poison ivy. Which symptoms should the nurse tell the client to report to the healthcare provider?

• A. Rapid weight gain
• B. Abdominal striae
• C. Moon faces
• D. Gastric irritation

Correct answer: A

Rationale: Rapid weight gain can indicate fluid retention, which is a serious side effect of prednisone and should be reported.

2. A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

• A. Carbon dioxide is converted in the kidneys for elimination.
• B. Blood oxygen levels are stimulating the respiratory rate.
• C. Hyperventilation is eliminating carbon dioxide rapidly.
• D. High levels of carbon dioxide have accumulated in the blood.

Correct answer: D

Rationale: The correct answer is D. High levels of carbon dioxide in the blood are indicative of respiratory acidosis, often due to inadequate ventilation. In respiratory acidosis, there is retention of carbon dioxide (hypercapnia) leading to an increase in carbonic acid levels in the blood, resulting in an acidic pH. Option A is incorrect because carbon dioxide elimination primarily occurs through the lungs, not the kidneys. Option B is incorrect because blood oxygen levels primarily affect the respiratory rate to regulate oxygen levels, not carbon dioxide levels. Option C is incorrect because hyperventilation would lead to a decrease, not an increase, in carbon dioxide levels.

3. Which of the following is the best indicator of fluid balance in a patient with heart failure?

• A. Daily weight measurements.
• B. Monitoring intake and output.
• C. Assessing skin turgor.
• D. Checking for peripheral edema.

Correct answer: A

Rationale: Daily weight measurements are the best indicator of fluid balance in a patient with heart failure. Changes in weight reflect fluid retention or loss more accurately than other methods. Monitoring intake and output (choice B) is essential but may not provide a comprehensive picture of fluid status. Skin turgor (choice C) and checking for peripheral edema (choice D) are more indicative of dehydration and fluid overload, respectively, rather than overall fluid balance.

4. A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be to:

• A. Administer epinephrine.
• B. Inform the physician.
• C. Administer oxygen.
• D. Inform the client that the procedure is almost over.

Correct answer: B

Rationale: The correct immediate action for the nurse to take in this situation is to inform the physician. The symptoms described - nausea, tingling, and dyspnea - indicate a potential allergic reaction to the contrast dye used in the arteriogram. It is crucial to notify the physician promptly so that further assessment and appropriate interventions can be initiated. Administering epinephrine without physician guidance can be dangerous as the physician needs to evaluate the severity of the reaction and determine the necessary treatment. Administering oxygen may be needed but should be done under the physician's direction. Informing the client that the procedure is almost over is not a priority when the client is experiencing symptoms of a possible allergic reaction.

5. A client who has received sodium bicarbonate in large amounts is at risk for metabolic alkalosis. 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: D

Rationale: The correct answer is D. A client with metabolic alkalosis may present with dysrhythmias and a decreased respiratory rate and depth as the body tries to compensate by retaining carbon dioxide. Options A, B, and C do not typically correlate with the signs and symptoms of metabolic alkalosis. Disorientation, dyspnea, drowsiness, headache, tachypnea, dizziness, and paresthesias are not commonly associated with metabolic alkalosis. Therefore, they are incorrect choices.

Similar Questions