Nursing Elites

1. In a client with asthma who develops respiratory acidosis, what should the nurse expect the client's serum potassium level to be?

• A. normal
• B. elevated
• C. low
• D. unrelated to the pH

Correct answer: B

Rationale: In respiratory acidosis, the serum potassium level is expected to be elevated. This occurs because potassium shifts from cells into the bloodstream as a compensatory mechanism to maintain acid-base balance. Choices A, C, and D are incorrect. A normal potassium level is not expected in respiratory acidosis. A low potassium level is more commonly associated with alkalosis, not acidosis. The potassium level is indeed related to pH changes in respiratory acidosis, leading to the expected elevation.

2. Which nursing diagnosis has the highest priority for a client with insomnia?

• A. Ineffective breathing pattern
• B. Disturbed sensory perception
• C. Ineffective coping
• D. Sleep deprivation

Correct answer: A

Rationale: The correct answer is 'A: Ineffective breathing pattern.' When a client presents with insomnia, assessing for underlying causes is crucial. Sleep apnea, an airway issue, may be a contributing factor to the client's insomnia, making 'Ineffective breathing pattern' the priority. 'Disturbed sensory perception' focuses on alterations in touch, taste, or vision, which are not directly related to insomnia. 'Ineffective coping' addresses a client's inability to manage stress, which, although important, is not the priority in this case. 'Sleep deprivation' is a consequence of insomnia rather than a primary nursing diagnosis.

3. After discontinuing a peripherally inserted central line (PICC), what information is most important for the nurse to record?

• A. How the client tolerated the procedure.
• B. The length and intactness of the central line catheter.
• C. The amount of fluid left in the IV solution container.
• D. That a dressing was applied to the insertion site.

Correct answer: B

Rationale: The most important information for the nurse to record after discontinuing a peripherally inserted central line (PICC) is the length and intactness of the central line catheter. This is crucial for assessing any potential complications or safety issues post-removal. Choices A, C, and D are not as critical as ensuring the condition of the central line catheter. While noting the client's tolerance of the procedure is relevant for their care assessment, evaluating the central line's integrity takes precedence in this scenario.

4. Teaching the client with gonorrhea how to prevent reinfection and further spread is an example of

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. primary health care prevention

Correct answer: B

Rationale: The correct answer is B: secondary prevention. This type of prevention focuses on reducing the impact of a disease by early detection and treatment. In the case of gonorrhea, teaching the client how to prevent reinfection and further spread falls under secondary prevention because it aims to reduce the prevalence and morbidity of the disease. Choice A (primary prevention) involves measures to prevent the disease from occurring in the first place, such as vaccination. Choice C (tertiary prevention) focuses on managing the long-term consequences of a disease to prevent complications. Choice D (primary health care prevention) is not a recognized term in prevention strategies.

5. The chemotherapeutic agent 5-fluorouracil (5-FU) is ordered for a client as an adjunct measure to surgery. Which statement about chemotherapy is true?

• A. It is a local treatment affecting only tumor cells.
• B. It is a systemic treatment affecting both tumor and normal cells.
• C. It has not yet been proven an effective treatment for cancer.
• D. It is often the drug of choice because it causes few, if any, side effects.

Correct answer: B

Rationale: The correct answer is that chemotherapy is a systemic treatment affecting both tumor and normal cells. 5-FU, as an antimetabolic drug, inhibits DNA synthesis and interferes with cell replication systemically. It affects all rapidly growing cells, including malignant and normal ones. This drug is used as adjuvant therapy for various cancers. Choice A is incorrect because chemotherapy affects both tumor and normal cells, not just tumor cells. Choice C is incorrect as chemotherapy has been proven effective in treating cancer. Choice D is incorrect because chemotherapy often causes side effects like bone marrow depression, anorexia, stomatitis, nausea, and vomiting.

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