STUDY QUESTIONS WITH CORRECT DETAILED ANSWERS
{VERIFIED ANSWERS} |ALREADY GRADED A+ |NEWEST
UPLOAD 2025!!
A client with an acute exacerbation of systemic lupus erythematosus (SLE) is
hospitalized with incapacitating fatigue and fever. A urinalysis reveals proteinuria
and hematuria. The primary healthcare provider prescribes corticosteroids.
During the acute phase of the client's illness, what is most important for the nurse
to do?
1. Monitor intake and output and daily weight.
2. Allow for frequent, uninterrupted rest periods.
3. Institute seizure precautions.
4. Protect client from injury that may cause bleeding. - ANS -1. Monitor intake and
output and daily weight.
Look at the clues in the stem. Proteinuria and hematuria. When you see
proteinuria what do you need to worry about? The kidneys! Protein is a great big
molecule. The only way for protein to be seen in the urine is if there are holes in
the glomerulus. So the kidneys are being damaged. Thus, the nurse knows that
the biggest problem to "worry" about here is renal failure. The best methods for
monitoring fluid status and renal status for a client are to monitor I and O and
daily weights. (Also, remember that one weight doesn't mean anything. The
hematuria indicates that there has already been glomerular damage.)
2. Incorrect: Systemic lupus erythematosus (SLE) is an autoimmune disease. In
this disease, the body's immune system mistakenly attacks healthy tissue. It can
,affect the skin, joints, kidneys, brain, and other organs. Fatigue is a major
symptom so allowing for frequent, uninterrupted rest periods is important for this
client but monitoring for renal failure is more acute.
A client diagnosed with systemic lupus erythematosus (SLE) has been started on
hydroxychloroquine sulfate to decrease joint pain and swelling. What statement
by the client indicates to the nurse the medication teaching has been effective?
1. "I will be prone to infections while on this medication."
2. "I need to see my eye doctor at least once every year."
3. "I might develop a red rash on my nose and cheeks."
4. "I can stop this medicine after my symptoms are gone." - ANS -2. "I need to see
my eye doctor at least once every year."
Hydroxychloroquine sulfate(Plaquenil) is in the category of DMARDs (disease
modifying anti-rheumatic drug) and was originally developed to treat or prevent
malaria. When taken once or twice daily, this medication reduces swelling and
joint pain while also decreasing skin problems in Lupus clients. Though there are
relatively few side effects, the most serious is retinal toxicity which requires
treatment by an ophthalmologist. It is imperative for clients on this medication to
have an eye examination every 6 to 12 months.
here are several categories of medications used to treat SLE; however, none of
them should be stopped suddenly. The disappearance of symptoms generally
indicates the medication regime is working well, and the client should never
suddenly discontinue any medicine unless instructed to do so. Abruptly stopping
this drug increases the risk of an exacerbation of symptoms such as nephritis or
vasculitis
,A client returns from post anesthesia care unit (PACU) following a mastectomy
with a Jackson-Pratt drain in place. What action by the nurse is important?
1. Empty drain every eight hours.
2. Irrigate drain with NS every shift.
3. Drape tubing above breast incision.
4. Empty and compress bulb when 2/3 full. - ANS -4. Empty and compress bulb
when 2/3 full.
A Jackson-Pratt drain is not connected to wall suction, but instead uses gravity
and compression to create suction. For maximum efficiency, the bulb must be
emptied at only 2/3 capacity. If the bulb becomes filled, suction fails, and fluid will
build up in the tissues, possibly leading to wound dehiscence.
A client diagnosed with renal failure has been admitted to the medical unit. An
arterial blood gas (ABG) analysis has been prescribed by the primary healthcare
provider. Which ABG interpretation by the nurse is appropriate?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - ANS -1. Metabolic acidosis
Metabolic acidosis
pH - 7.33 (normal value 7.35 - 7.45) less than 7.35
PaCO2 36 mm Hg (normal value 35 - 45 mm Hg) within normal range
, HCO3 20 mEq/L (normal value 22 - 26 mEq/L) less than 22 mEq/L Metabolic
acidosis is reflected in a reduction of the HCO3 and pH levels.
Metabolic alkalosis is indicated by an elevated pH and HCO3 levels. The client's
HCO3 and the pH are below the normal range.
The primary issue with respiratory acidosis is an elevated CO2 level. The CO2 level
for this client is within the normal range.
With respiratory alkalosis the pH is greater than 7.45. The pH for this client is less
than 7.35 and the PaCO2 is within the normal range. The HCO3 value will
decrease or elevate depending if the pulmonary process is acute or chronic.
A client arrives by ambulance after being thrown from a horse. The client is pale,
clammy and tachycardic with bruising over left upper abdominal quadrant. The
nurse is aware what prescription by the primary healthcare provider takes
priority?
1. Obtain blood for type and cross match.
2. Administer hydromorphone IV for pain.
3. Increase Lactated Ringers to 150 mL/hour.
4. Send client to radiology for stat CAT scan. - ANS -1. Obtain blood for type and
cross match.
The signs and symptoms displayed by the client suggest a ruptured spleen and
shock. The greatest concern in this situation is internal bleeding and possible
emergency surgery. The client will need blood; therefore, the nurse should
immediately obtain blood for type and cross match.
{VERIFIED ANSWERS} |ALREADY GRADED A+ |NEWEST
UPLOAD 2025!!
A client with an acute exacerbation of systemic lupus erythematosus (SLE) is
hospitalized with incapacitating fatigue and fever. A urinalysis reveals proteinuria
and hematuria. The primary healthcare provider prescribes corticosteroids.
During the acute phase of the client's illness, what is most important for the nurse
to do?
1. Monitor intake and output and daily weight.
2. Allow for frequent, uninterrupted rest periods.
3. Institute seizure precautions.
4. Protect client from injury that may cause bleeding. - ANS -1. Monitor intake and
output and daily weight.
Look at the clues in the stem. Proteinuria and hematuria. When you see
proteinuria what do you need to worry about? The kidneys! Protein is a great big
molecule. The only way for protein to be seen in the urine is if there are holes in
the glomerulus. So the kidneys are being damaged. Thus, the nurse knows that
the biggest problem to "worry" about here is renal failure. The best methods for
monitoring fluid status and renal status for a client are to monitor I and O and
daily weights. (Also, remember that one weight doesn't mean anything. The
hematuria indicates that there has already been glomerular damage.)
2. Incorrect: Systemic lupus erythematosus (SLE) is an autoimmune disease. In
this disease, the body's immune system mistakenly attacks healthy tissue. It can
,affect the skin, joints, kidneys, brain, and other organs. Fatigue is a major
symptom so allowing for frequent, uninterrupted rest periods is important for this
client but monitoring for renal failure is more acute.
A client diagnosed with systemic lupus erythematosus (SLE) has been started on
hydroxychloroquine sulfate to decrease joint pain and swelling. What statement
by the client indicates to the nurse the medication teaching has been effective?
1. "I will be prone to infections while on this medication."
2. "I need to see my eye doctor at least once every year."
3. "I might develop a red rash on my nose and cheeks."
4. "I can stop this medicine after my symptoms are gone." - ANS -2. "I need to see
my eye doctor at least once every year."
Hydroxychloroquine sulfate(Plaquenil) is in the category of DMARDs (disease
modifying anti-rheumatic drug) and was originally developed to treat or prevent
malaria. When taken once or twice daily, this medication reduces swelling and
joint pain while also decreasing skin problems in Lupus clients. Though there are
relatively few side effects, the most serious is retinal toxicity which requires
treatment by an ophthalmologist. It is imperative for clients on this medication to
have an eye examination every 6 to 12 months.
here are several categories of medications used to treat SLE; however, none of
them should be stopped suddenly. The disappearance of symptoms generally
indicates the medication regime is working well, and the client should never
suddenly discontinue any medicine unless instructed to do so. Abruptly stopping
this drug increases the risk of an exacerbation of symptoms such as nephritis or
vasculitis
,A client returns from post anesthesia care unit (PACU) following a mastectomy
with a Jackson-Pratt drain in place. What action by the nurse is important?
1. Empty drain every eight hours.
2. Irrigate drain with NS every shift.
3. Drape tubing above breast incision.
4. Empty and compress bulb when 2/3 full. - ANS -4. Empty and compress bulb
when 2/3 full.
A Jackson-Pratt drain is not connected to wall suction, but instead uses gravity
and compression to create suction. For maximum efficiency, the bulb must be
emptied at only 2/3 capacity. If the bulb becomes filled, suction fails, and fluid will
build up in the tissues, possibly leading to wound dehiscence.
A client diagnosed with renal failure has been admitted to the medical unit. An
arterial blood gas (ABG) analysis has been prescribed by the primary healthcare
provider. Which ABG interpretation by the nurse is appropriate?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - ANS -1. Metabolic acidosis
Metabolic acidosis
pH - 7.33 (normal value 7.35 - 7.45) less than 7.35
PaCO2 36 mm Hg (normal value 35 - 45 mm Hg) within normal range
, HCO3 20 mEq/L (normal value 22 - 26 mEq/L) less than 22 mEq/L Metabolic
acidosis is reflected in a reduction of the HCO3 and pH levels.
Metabolic alkalosis is indicated by an elevated pH and HCO3 levels. The client's
HCO3 and the pH are below the normal range.
The primary issue with respiratory acidosis is an elevated CO2 level. The CO2 level
for this client is within the normal range.
With respiratory alkalosis the pH is greater than 7.45. The pH for this client is less
than 7.35 and the PaCO2 is within the normal range. The HCO3 value will
decrease or elevate depending if the pulmonary process is acute or chronic.
A client arrives by ambulance after being thrown from a horse. The client is pale,
clammy and tachycardic with bruising over left upper abdominal quadrant. The
nurse is aware what prescription by the primary healthcare provider takes
priority?
1. Obtain blood for type and cross match.
2. Administer hydromorphone IV for pain.
3. Increase Lactated Ringers to 150 mL/hour.
4. Send client to radiology for stat CAT scan. - ANS -1. Obtain blood for type and
cross match.
The signs and symptoms displayed by the client suggest a ruptured spleen and
shock. The greatest concern in this situation is internal bleeding and possible
emergency surgery. The client will need blood; therefore, the nurse should
immediately obtain blood for type and cross match.
