Exhibits

The nurse has implemented additional needed actions.

Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one answer selected.

Blood pressure 122/84 mmHg

Heart rate 105 beats/minute

Client can now speak in full sentences without pausing.

Respirations 16 breaths/minute

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}

Indicates the Interventions Were Successful:

Client can now speak in full sentences without pausing. This shows an improvement in the client's breathing and overall respiratory function.
Respirations 16 breaths/minute. This is a normal respiratory rate, indicating that the client's breathing has stabilized.

No Indication that the Interventions Were Successful:

Blood pressure 122/84 mmHg. While this is a normal blood pressure reading, it does not specifically indicate the success of the interventions for an asthma attack.
Heart rate 105 beats/minute. Although slightly improved, this heart rate is still elevated and does not clearly indicate the success of the interventions.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","E","F"]

Explanation

A. Nonsmoker: Smoking does not directly contribute to the development of gout. While smoking is a risk factor for many health conditions, it is not a major contributor to the elevated uric acid levels associated with gout.

B. Obesity: Obesity is a well-established risk factor for gout because it leads to increased production of uric acid and reduced renal excretion of uric acid. Higher body fat increases the likelihood of developing hyperuricemia (elevated uric acid levels in the blood), which can form crystals in the joints, leading to gout.

C. Drinks beer nightly: Alcohol, particularly beer, is a significant risk factor for gout. Beer contains high levels of purines, which are broken down into uric acid in the body. Chronic alcohol consumption, especially beer, increases uric acid levels, contributing to the formation of uric acid crystals in the joints, which leads to gout attacks.

D. Daily aspirin: Aspirin, particularly at low doses, can reduce the excretion of uric acid by the kidneys, which can increase the risk of hyperuricemia and gout. However, this effect is typically observed with chronic, low-dose aspirin use, which is not indicated here in the patient's history.

E. Type 2 diabetes mellitus: Type 2 diabetes mellitus is associated with insulin resistance, which impairs the kidney's ability to excrete uric acid. As a result, uric acid builds up in the bloodstream, increasing the risk of gout. Additionally, people with type 2 diabetes often have comorbidities (such as obesity) that further increase the risk of gout.

F. Sleep apnea: Obstructive sleep apnea is associated with intermittent hypoxia (lack of oxygen), which can contribute to the production of uric acid and decreased renal clearance. This increase in uric acid levels raises the risk of hyperuricemia and subsequently gout. Sleep apnea can also be related to metabolic syndrome, which is another risk factor for gout.

A. Elevated creatinine and blood urea nitrogen (BUN). B. Hypovolemia and electrocardiographic (ECG) changes. C. Uremic irritation of mucous membranes and skin surfaces. D. Side effects of total parenteral nutrition (TPN) and intralipids.

Correct Answer is B

Explanation

A. While elevated creatinine and BUN are important indicators of kidney function, in the diuretic phase, the focus shifts to monitoring for complications, particularly fluid and electrolyte balance.

B. Hypovolemia can occur due to excessive diuresis during the diuretic phase, which can lead to significant cardiovascular effects, including ECG changes related to electrolyte imbalances, particularly potassium levels.

C. Monitoring for uremic irritation is important but less critical than monitoring for hypovolemia and ECG changes that can lead to acute complications.

D. While monitoring for side effects of TPN is relevant, it is not the priority in the context of AKI transitioning phases where fluid and electrolyte balance are paramount.

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Exhibits The nurse has implemented additional needed actions. Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one answer selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Client history has been collected, and the nurse performs a physical assessment and records vital signs. Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.

Correct Answer is ["B","C","E","F"]

Explanation

A client who has developed acute kidney injury (AKI) due to an aminoglycoside antibiotic has moved from the oliguric phase to the diuretic phase of AKI. Which parameters are most important for the nurse to plan to carefully monitor?

Correct Answer is B

Explanation

A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?

A client receives a prescription for 2 liters of lactated Ringer's IV to be infused over 20 hours. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Following a lumbar puncture, a client voices several concerns. Which concern indicates to the nurse that the client is experiencing a complication of the procedure?

An older adult client with cirrhosis of the liver and hepatic failure is placed on a low sodium diet and is receiving periodic albumin infusions. Which assessment finding indicates progress toward the desired effect of this treatment plan?

A client with leukemia is receiving chemotherapy. The nurse observes the client is weak, pale, and febrile. After reviewing the client's most recent laboratory results which reveals a platelet count of 25,000/mm3 (25 x 10^9/L), which intervention should the nurse include in the plan of care?

Exhibits

The nurse has implemented additional needed actions.

Click the assessment data which indicates the interventions were successful and which assessment data provides no indication that the interventions were successful. Each column must have at least one answer selected.