- (Topic 7)
The nurse writes the following nursing diagnosis for a client in acute renal failure—Impaired
gas exchange related to:
Correct Answer:A
(A) Red blood cell production is impaired in renal failure owing to impaired erythropoietin production. This causes a decrease in the delivery of oxygen to the tissue and impairs gas exchange. (B) The conversion of vitamin D to its physiologically active form is impaired in renal failure. (C) In renal failure, a decrease in red blood cell production occurs owing to an impaired production of erythropoietin, leading to impaired gas exchange at the cellular level. (D) The decreased production of renin in renal failure causes an increased production of aldosterone causing sodium and water retention.
- (Topic 7)
A 9-year-old child was in the garage with his father, who was repairing a lawnmower. Some gasoline ignited and caused an explosion. His father was killed, and the child has split- thickness and full-thickness burns over 40% of his upper body, face, neck, and arms. All of the following nursing diagnoses are included on his care plan. Which of these nursing diagnoses should have top priority during the first 24–48 hours postburn?
Correct Answer:D
(A, B, C) These answers are all correct; however, maintenance of airway is the top priority.
(D) Persons burned about the face and neck during an explosion are also likely to suffer burns of the respiratory tract, which can lead to edema and respiratory arrest.
- (Topic 1)
The priority nursing goal when working with an autistic child is:
Correct Answer:A
(A) The priority nursing goal when working with an autistic child is establishing a trusting relationship. (B) Maintaining a relationship with the family is important but having the trust of the child is a priority. (C) To promote involvement in school activities is inappropriate for a child who is autistic. (D) Maintaining nutritional requirements is not the primary problem of the autistic child.
- (Topic 4)
A client is admitted to the hospital with diabetic ketoacidosis.
The emergency room nurse should anticipate the administration of:
Correct Answer:B
(A) Intermediate-acting insulin is not indicated in an emergency. (B) Regular insulin is rapid acting and indicated in an emergency situation. (C) Long-acting insulin is not indicated in an emergency situation. (D) Intermediate-acting insulin is not indicated in an emergency situation.
- (Topic 7)
The nurse enters the room of a client on which a ??do not resuscitate?? order has been written and discovers that she is not breathing. Once the husband realizes what has occurred he yells, ??please save her!?? The nurse??s action would be:
Correct Answer:D
(A, B, C) The last request from the husband overrides the decision not to initiate resuscitation efforts. (D) The nurse should begin cardiopulmonary resuscitation unless a living will and durable power of attorney are in force. In the meantime, the nurse should talk with the husband and notify the doctor.