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Questions 158

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Extract:


Question 1 of 5

Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?

Correct Answer: C

Rationale: Increased PaCO2 is present in both acute and chronic respiratory acidosis due to hypoventilation. Decreased PaO2 may occur in respiratory acidosis but does not differentiate acute from chronic. Increased HCO3 indicates renal compensation, which occurs in chronic respiratory acidosis as the body attempts to buffer the excess CO2, but not in acute cases where compensation has not yet occurred. Decreased base excess is not specific to differentiating acute from chronic respiratory acidosis.

Question 2 of 5

The nurse is caring for a client with B-thalassemia major. Which therapy is used to treat B-thalassemia major?

Correct Answer: B

Rationale: B-thalassemia major causes severe anemia due to defective hemoglobin synthesis, requiring frequent blood transfusions to maintain hemoglobin levels. IV fluids, oxygen, and iron therapy (which can cause overload) are not primary treatments.

Question 3 of 5

Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. Which of the following nursing observations indicates that the drug is having a therapeutic effect?

Correct Answer: B

Rationale: Lomotil, an antidiarrheal, slows intestinal motility, reducing diarrhea frequency in ulcerative colitis. Decreased diarrhea stools (
B) indicates therapeutic effect. Absent peristalsis (
A), increased cramping (
C), or girth (
D) suggest complications or ineffectiveness.

Question 4 of 5

The client is diagnosed with multiple myeloma. The doctor has ordered cyclophosphamide (Cytoxan). Which instruction should be given to the client?

Correct Answer: D

Rationale: Cyclophosphamide can cause hemorrhagic cystitis, so adequate hydration (e.g., 8 glasses of water daily) is essential to flush the bladder and reduce this risk. Walking, fiber, and nausea reporting are not primary concerns with this drug.

Question 5 of 5

An 18-year-old girl is admitted to the hospital with a depressed skull fracture as a result of a car accident. If the nurse were to observe a rising pulse rate and lowering blood pressure, the nurse would suspect that the client:

Correct Answer: B

Rationale: Rising pulse rate and lowering blood pressure are indicative of hypovolemia, which is consistent with an internal injury causing blood loss.

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