A prescribed measure of oxygen is required for a patient with COPD to prevent
A. Cardiac arrest related to the increased partial pressure of carbon dioxide in arterial blood
B. Circulatory overload due to hypervolemia
C. Respiratory excitement
D. Inhibition of the respiratory hypoxic stimulus
Answer D. Delivery of more than two liters of oxygen per minute to a patient with chronic obstructive pulmonary disease (COPD) who is normally in a situation of compensated respiratory acidosis retaining carbon dioxide can inhibit the hypoxic stimulus for respiration. An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not originally result in cardiac arrest. Circulatory overload and respiratory excitement have no connection to the question.
After one week of hospitalization, Mr. Bong Tayamen reveals hypokalemia low potassium. Which of the following is the most important symptom of his disorder?
B. Increased pulse rate and blood pressure
C. Muscle weakness
D. Muscle irritability
Answer C. Showing signs of hypokalemia a serum potassium level below 3.5 mEq/liter involve muscle weakness, chronic fatigue, and cardiac dysrhythmias. The mixed results of inadequate food intake and prolonged diarrhea can drain the potassium stores of a patient with GI problems.
An extra Vitamin C is needed during all of the following periods except
B. Young adulthood
Answer B. Vitamin C is needed in growth periods such as infancy and childhood, and during pregnancy to fulfill the demands for fetal growth. Other situations needing extra vitamin C include wound healing, fever, infection, and stress.
Mrs. Tayamen starts to cry as the nurse explains hair loss. The best reply would be
A. “Don’t worry. It’s only temporary”
B. “Why are you crying? I didn’t get to the bad news yet”
C. “Your hair is really pretty”
D. “I understand this will be hard for you, but your hair will turn back after the end of chemotherapy”
Answer D. “I understand this will be difficult” recognizes the problem and suggests a purpose to it.
A female patient who had surgery head and neck cancer is about to get his first try to ambulate outside his room. The r.N sees that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing action would be suitable?
A. Help the patient to walk in the hall alone
B. Discourage the patient from walking in the hallway for a few more days
C. Escort the patient for his walk.
D. Ask a physical therapist before allowing the patient to ambulate
Answer C. A hospitalized surgical patient moving his room for the first time worries rejection and others staring at him, so he should not walk alone. Escorting him will offer moral support, allowing him to face the rest of the world. Patients should start ambulation as soon as possible after surgery to reduce complexities and to regain strength and confidence. Waiting to consult a physical therapist is unnecessary.
Some substances increase the amount of urine produced. These include:
A. Caffeine-containing drinks, such as coffee and cola.
C. Urinary analgesics
D. Kaolin with pectin (Kaopectate)
Answer A. Fluids including caffeine have a diuretic effect. Beets and urinary analgesics can color urine red. Kaopectate is an anti-diarrheal medicine.
Nclex Nursing Queston and Rationale related to the subject of psychiatric nursing.
To evaluate the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse covers his hourly urine output. She should inform the physician if the urine output is
A. Less than 30 ml/hour
B. 64 ml in 2 hours
C. 90 ml in 3 hours
D. 125 ml in 4 hours
Answer A. A urine amount of less than 30ml/hour means hypovolemia which is linked to kidney function and inadequate fluid intake.
Which of the following description is wrong about a patient with dysphagia?
A. The patient will find pureed such as custards, easier to swallow than water
B. Fowler’s position reduces the hazard of aspiration when swallowing
C. The patient should always feed himself
D. The r.N should give oral hygiene before assisting with feeding.
Answer C. A patient with dysphagia (difficulty swallowing) needs assistance with feeding. Feeding himself is a long-range expected outcome
The most popular deficiency observed in alcoholics is
D. Pantothenic acid
Answer A. Chronic alcoholism usually occurs in thiamine deficiency and other symptoms of malnutrition.
The doctor orders high-humidity oxygen by face mask and position of the patient in a high Fowler’s position. After evaluating Mrs. Bong Tayamen, the r.N addresses the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the highest potential for developing this condition?
A. Help the patient to improve her fluid intake
B. Put a humidifier in the patient’s room.
C. Resume administering oxygen by high humidity face mask
D. Make chest physiotherapy on a regular schedule
Answer A. Adequate hydration relaxes pulmonary secretions to replenish fluids lost from elevated temperature, diaphoresis, dehydration, and dyspnea. High-humidity air help dissolve and mobilize secretions.