Extract:

Question 1 of 5

The nurse is preparing discharge teaching for a client who is recently diagnosed with Multiple sclerosis. Which of the following is the most important to include in the patient teaching?

A. Limit fluid intakeB. Utilize assistive devices as neededC. Schedule eye examinations every other yearD. Double up on any missed scheduled medications

Correct Answer: B

Rationale: Using assistive devices like canes or walkers enhances mobility and safety, critical for MS patients with weakness and coordination issues.

Question 2 of 5

What condition do these results indicate? A nurse is reviewing arterial blood gas lab values on her newly admitted elderly client. The ABG results are as follows: pH 7.21, PaCO2 50, HCO3 26.

A. Respiratoty acidosisB. Metabolic alkalosisC. Respiratory alkalosisD. Metabolic acidosis

Correct Answer: A

Rationale: The pH of 7.21 indicates acidosis, and the elevated PaCO2 of 50 mmHg suggests carbon dioxide retention, characteristic of respiratory acidosis due to inadequate CO2 expulsion.

Question 3 of 5

A nurse in the med-surgical ICU is evaluating a patient with a diagnosis of chronic copd. The patient is receiving oxygen at a flow rate of 10 L/min via facemask. Which finding would concern the nurse to act immediately?

A. Respiratory rate of 8 bpmB. A large barrel chestC. Fine cracklesD. The patient assumes the orthopenic position

Correct Answer: A

Rationale: A respiratory rate of 8 bpm indicates respiratory depression, potentially due to high-flow oxygen suppressing the respiratory drive in COPD patients, requiring immediate intervention.

Question 4 of 5

A nurse working in the Neuro ICU is caring for a client who has been recently diagnosed with Guillain Barre Syndrome. Which of the following clinical manifestations should the nurse assess for?

A. Unilateral upper extremity weaknessB. Bilateral ascending weaknessC. Mask like facial expressionsD. Pill rolling actions made by the clients fingers

Correct Answer: B

Rationale: Bilateral ascending weakness, starting in the lower extremities, is a hallmark of GBS due to autoimmune attack on peripheral nerve myelin.

Question 5 of 5

A nurse is teaching a client who has angina pectoris about starting therapy with nitroglycerin tablets. The nurse should include which of the following instructions regarding how to take the medication?

A. Take one tablet every 15 during an acute attack.'B. Take this medication after each meal and at bedtime.'C. Take one tablet at the first indication of chest pain.'D. Take this medication with 8 ounces of water.'

Correct Answer: C

Rationale: Taking nitroglycerin at the first sign of chest pain ensures rapid relief by dilating coronary arteries.