Nursing Elites

1. A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs and symptoms of respiratory alkalosis 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: C

Rationale: The correct answer is C: Tachypnea, dizziness, and paresthesias. When a client is anxious, they may hyperventilate, leading to respiratory alkalosis. Tachypnea (rapid breathing) is a common sign of respiratory alkalosis. Dizziness and paresthesias (tingling or numbness in the extremities) are also typical symptoms. Choices A, B, and D are incorrect. Disorientation and dyspnea (Choice A) are not specific signs of respiratory alkalosis. Drowsiness, headache, and tachypnea (Choice B) may be more indicative of other conditions. Dysrhythmias and decreased respiratory rate and depth (Choice D) are not consistent with the expected signs of respiratory alkalosis.

2. A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following?

• A. I am having fewer aches and pains.
• B. I do not have headaches anymore.
• C. I am able to walk further without leg pain.
• D. My toes are turning grayish black in color.

Correct answer: C

Rationale: The correct answer is C. Cilostazol improves blood flow to the muscles, which helps alleviate symptoms of intermittent claudication. An improvement in walking distance without leg pain indicates the effectiveness of the medication. Choices A and B are not directly related to the expected outcome of Cilostazol therapy for intermittent claudication. Choice D is concerning for a potential adverse effect and should be reported to the healthcare provider immediately.

3. A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention?

• A. A 29-year-old client after a difficult vaginal delivery – Habit training
• B. A 58-year-old postmenopausal client who is not taking estrogen therapy – Electrical stimulation
• C. A 64-year-old female with Alzheimer’s-type senile dementia – Bladder training
• D. A 77-year-old female who has difficulty ambulating – Exercise therapy

Correct answer: B

Rationale: The correct pairing is a 58-year-old postmenopausal client who is not taking estrogen therapy with electrical stimulation. Electrical stimulation is used for clients with stress incontinence related to menopause and low estrogen levels. Exercise therapy improves pelvic wall strength and is not specifically for ambulation issues. Habit training is more effective for cognitively impaired clients, like those with Alzheimer's-type senile dementia. Bladder training requires the client to be alert, aware, and able to resist the urge to urinate, which may not be suitable for clients with cognitive impairments.

4. The nurse is obtaining the admission history for a client with suspected peptic ulcer disease (PUD). Which subjective data reported by the client supports this diagnosis?

• A. Frequent use of chewable and liquid antacids for indigestion
• B. Severe abdominal cramps and diarrhea after eating spicy foods
• C. Upper mid-abdominal gnawing and burning pain
• D. Marked weight loss and appetite over the last 3 to 4 months

Correct answer: C

Rationale: The correct answer is C: 'Upper mid-abdominal gnawing and burning pain.' This symptom is a classic presentation of peptic ulcer disease. Antacids (choice A) may provide relief but do not confirm the diagnosis. Severe abdominal cramps and diarrhea (choice B) are more suggestive of other conditions like irritable bowel syndrome. Weight loss and appetite changes (choice D) are non-specific and could be related to various health issues.

5. The nurse is preparing to administer the first dose of an antibiotic to a patient admitted for a urinary tract infection. Which action is most important prior to administering the antibiotic?

• A. Administering a small test dose to determine if hypersensitivity exists
• B. Having epinephrine available in case of a severe hypersensitivity reaction
• C. Monitoring baseline vital signs, including temperature and blood pressure
• D. Obtaining a specimen for culture and sensitivity

Correct answer: D

Rationale: The most crucial action before administering an antibiotic for a urinary tract infection is to obtain a specimen for culture and sensitivity. This ensures the accurate identification of the causative organism and helps determine the most effective antibiotic therapy. Administering a test dose to detect hypersensitivity is usually reserved for cases with a strong suspicion of allergy to a needed antibiotic. Keeping epinephrine available is important when there is a significant risk of a severe allergic reaction. Monitoring baseline vital signs is essential during antibiotic therapy but is not the top priority before administering the first dose.

Similar Questions