NU 160 Exam 1

Correct Answer: B. Respiratory Alkalosis

Why the Correct Answer Is Respiratory Alkalosis:

Step 1: Determine if the pH is normal, acidic, or alkalotic.

pH = 7.50 (above normal range) → Indicates alkalosis

Step 2: Identify if the cause is respiratory or metabolic.

PaCO₂ = 22 mmHg (low) → Since CO₂ is acidic, a low PaCO₂ suggests excessive CO₂ loss (which makes the blood more alkaline).

HCO₃⁻ = 22 mEq/L (normal) → Since bicarbonate (a base) is within the normal range, the cause is not metabolic.

Conclusion:

Alkalotic pH + Low PaCO₂ + Normal HCO₃⁻ = Respiratory Alkalosis

Why the Other Options Are Incorrect:

A. Metabolic Acidosis

Acidosis means the pH would be low (<7.35), but in this case, the pH is high (alkalotic). HCO₃⁻ is normal; if metabolic acidosis were present, bicarbonate would be low (<22 mEq/L).

C. Metabolic Alkalosis

In metabolic alkalosis, HCO₃⁻ would be elevated (>26 mEq/L). Here, HCO₃⁻ is normal (22 mEq/L), ruling out a metabolic cause.

D. Respiratory Acidosis

Respiratory acidosis occurs when PaCO₂ is high (>45 mmHg), leading to a low pH (<7.35). In this case, PaCO₂ is low (22 mmHg) and pH is high, which is the opposite of respiratory acidosis.

Additional Considerations:

The PaO₂ of 42 mmHg is severely low, indicating hypoxemia

Common causes of respiratory alkalosis include:

Hyperventilation (due to anxiety, pain, fever, or hypoxia).

Pulmonary disorders (such as pulmonary embolism, pneumonia, or high-altitude sickness).

Mechanical ventilation set at high respiratory rates.

Summary:

This ABG result indicates respiratory alkalosis, as shown by high pH, low PaCO₂, and normal HCO₃⁻. The low PaO₂ suggests the presence of hypoxemia, which might be causing the hyperventilation leading to CO₂ loss.

Correct Answer: A typical course of treatment involves 6 to 9 months of consistent medication use.

Explanation:

Pulmonary tuberculosis (TB) requires long-term treatment with multiple antitubercular medications to ensure complete eradication of Mycobacterium tuberculosis and prevent drug resistance. The standard course of treatment lasts 6 to 9 months, typically including isoniazid (INH), rifampin (RIF), ethambutol (EMB), and pyrazinamide (PZA) during the initial phase. After the first 2 months, isoniazid and rifampin are continued for the remaining 4 to 7 months. Strict adherence is necessary for treatment success and to prevent multi-drug resistant TB (MDR-TB).

Why the Other Options Are Incorrect

"Medications will need to be taken for the rest of the client's life, even if the client feels better."

Incorrect because TB treatment is typically completed within 6 to 9 months. Lifelong therapy is not required unless the client has complications like extensively drug-resistant TB (XDR-TB) or HIV-related TB.

"Medications will need to be taken until the Mantoux test is negative."

Incorrect because a Mantoux (TB skin test) remains positive even after successful treatment. Instead, sputum cultures and chest X-rays are used to determine treatment effectiveness.

"The client's family will also need to take medications to prevent infection."

Incorrect because preventive treatment is only recommended for close contacts who test positive for latent TB infection (LTBI). Family members should undergo Mantoux or IGRA (interferon-gamma release assay) testing, and only those who test positive for latent TB may require isoniazid (INH) prophylaxis for 6 to 9 months.

Summary:

The standard treatment for pulmonary TB lasts 6 to 9 months and requires strict adherence to prevent drug resistance and relapse. Treatment is not lifelong, and the Mantoux test does not determine completion. Family members only need treatment if they test positive for latent TB infection (LTBI).

The correct answer is: History of drug and alcohol use.

Explanation:

Delirium is an acute state of confusion that can develop due to various risk factors, including underlying medical conditions, substance use, and acute illness. 

Substance withdrawal: Clients with a history of alcohol or drug use are at risk for withdrawal delirium (delirium tremens in alcohol withdrawal) when hospitalized.

Toxic effects of substances: Chronic drug or alcohol use can lead to neurotoxicity, increasing susceptibility to delirium.

Liver dysfunction: Long-term substance use can impair liver function, leading to metabolic imbalances and toxin buildup, which contribute to delirium.

Why the other options are incorrect:

History of lymphoma:

While serious illnesses can contribute to delirium, lymphoma alone is not a direct cause unless the disease is advanced and causing metabolic disturbances, infections, or chemotherapy-related toxicity.

Lack of medical insurance:

Socioeconomic factors can impact access to care but do not directly cause delirium

Female sex:

Although age and certain health conditions may increase the risk of delirium, gender alone is not a major risk factor for its development.

Summary:

A history of drug and alcohol use is the most significant risk factor among the options provided, as it increases the likelihood of withdrawal symptoms, neurotoxicity, and metabolic imbalances, all of which can trigger delirium.

Correct Answer: Elevated central venous pressure (CVP).

Explanation:

In right-sided heart failure, the right side of the heart is unable to effectively pump blood to the lungs, leading to backward blood flow into the systemic circulation. This causes fluid retention and congestion in the venous system, including the venous pressure in the body.

Elevated central venous pressure (CVP) is a common finding in right-sided heart failure because of the increased volume and pressure in the veins, particularly the jugular veins, and other areas like the liver and legs

Why the Other Options Are Incorrect:

Decreased brain natriuretic peptide (BNP): BNP is typically elevated in heart failure because it is released in response to increased ventricular stretch. In both right and left heart failure, BNP levels are generally elevated as a compensatory mechanism.

Increased pulmonary artery wedge pressure (PAWP): PAWP is a measurement that primarily reflects left-sided heart function and is typically elevated in left-sided heart failure due to increased pulmonary venous pressure. It may not be elevated in right-sided heart failure unless there is also a component of left-sided failure.

Decreased specific gravity: Specific gravity refers to the concentration of urine. In right-sided heart failure, the kidneys retain fluid due to the reduced perfusion and congestion, which usually leads to increased specific gravity, not decreased. Decreased specific gravity would suggest a dilute urine, which is not typically associated with heart failure

Summary:

In right-sided heart failure, an elevated central venous pressure (CVP) is expected due to fluid retention and venous congestion. BNP levels are usually elevated, and PAWP is increased in left-sided heart failure, not right-sided. Additionally, specific gravity tends to be increased, not decreased, in right-sided heart failure.

Correct Answer: B. Check the tubing for kinks.

Explanation:

The first action the nurse should take is to check the tubing for kinks or obstruction. A kinked or twisted catheter tube can block urine flow, leading to bladder distension and discomfort. This is the least invasive and quickest action to restore drainage before considering other interventions.

Why the Other Options Are Incorrect:

A. Notify the provider.

This is incorrect as the first action. The nurse should assess the catheter tubing for kinks and other potential obstructions before escalating the issue to the provider. If troubleshooting measures do not resolve the issue, then the provider should be notified.

C. Adjust the rate of the bladder irrigant.

This is incorrect because adjusting the irrigation flow rate without first identifying the cause of the blockage can worsen the problem. If the tubing is kinked, increasing the irrigation flow will not resolve the obstruction. Proper assessment should come first

D. Irrigate the catheter.

This is incorrect as the first action. While irrigation may be necessary if there is a clot or blockage, it should not be done before assessing the tubing for external kinks or twists. Unnecessary irrigation can introduce bacteria and increase infection risk.

Summary:

The correct answer is B, as checking for kinks is the simplest and least invasive way to restore urine flow. If the tubing is not kinked and the catheter remains blocked, further interventions such as irrigation or provider notification may be necessary.

Correct Answer: "I eat two eggs for breakfast each morning."

Explanation:

Egg yolks are high in dietary cholesterol, with one egg containing approximately 186 mg of cholesterol. The American Heart Association (AHA) recommends limiting dietary cholesterol intake, especially for individuals with a history of atherosclerosis, to help manage cholesterol levels and reduce the risk of cardiovascular disease. Eating two eggs daily could contribute to elevated cholesterol levels, indicating the need for follow-up dietary education.

Why the Other Options Are Correct Choices for a Low-Cholesterol Diet:

"I flavor my meat with lemon juice."

Lemon juice is a heart-healthy alternative to butter, salt, or high-fat sauces for seasoning meat.

"I cook my food with canola oil." –

Canola oil is low in saturated fat and contains heart-healthy monounsaturated fats, which help lower LDL ("bad") cholesterol.

"I take an omega-3 supplement daily." – 

Omega-3 fatty acids (found in supplements and fatty fish) help reduce triglycerides and inflammation, supporting heart health.

Summary:

Since eggs contain high amounts of dietary cholesterol, eating two eggs for breakfast daily is not ideal for someone with atherosclerosis and high cholesterol levels. The client would benefit from education on limiting egg consumption or opting for egg whites instead.

Correct Answer: A. "Sit upright or stand for at least 30 minutes after taking this medication."

Explanation:

Alendronate is a bisphosphonate used to treat and prevent osteoporosis by inhibiting bone resorption. However, it can cause severe esophageal irritation, ulceration, and reflux. To reduce this risk, the patient must remain upright for at least 30 minutes after taking it to prevent reflux and esophageal damage.

Why the Other Options Are Incorrect:

B. "Take this medication with food." – Incorrect because food interferes with the absorption of alendronate. It should be taken on an empty stomach with a full glass of water at least 30 minutes before eating or drinking anything else.

C. "Take this medication with orange juice." – Incorrect because orange juice (or any acidic drink) can interfere with the medication’s absorption. Alendronate should only be taken with plain water.

D. "Chew or suck on the tablet." – Incorrect because alendronate tablets must be swallowed whole. Chewing or sucking on them increases the risk of oropharyngeal and esophageal irritation.

Summary:

The correct answer is A because sitting upright for at least 30 minutes helps prevent esophageal irritation. The other options are incorrect because food and acidic drinks affect absorption, and chewing increases the risk of irritation.

Correct Answers:

B. Developing culturally appropriate outcomes.

D. Involving the patient and family in formulating outcomes.

Explanation:

The American Nurses Association (ANA) Standards for Outcomes Identification emphasize patient-centered, culturally competent, and collaborative care when planning outcomes.

Why These Options Are Correct:

 B. Developing culturally appropriate outcomes.

Nurses must consider cultural beliefs, values, and preferences when setting patient goals. For a patient of Chinese heritage, this may include traditional healing practices, family decision-making, and dietary considerations.

 D. Involving the patient and family in formulating outcomes.

Many Asian cultures, including Chinese, emphasize family involvement in healthcare decisions. The ANA standards encourage collaboration between patients, families, and healthcare teams to develop appropriate, achievable outcomes.

Why the Other Options Are Incorrect:

 A. Using the outcomes preprinted on the clinical pathway.

Preprinted pathways may not be individualized to the patient's unique cultural, personal, or medical needs. Standardized pathways can be used as a guide, but customization is essential for patient-centered care.

 C. Doing whatever it takes for the patient, no matter the cost.

While advocating for patients is important, resource limitations and ethical considerations must be balanced. The ANA emphasizes evidence-based, sustainable care, not just unlimited interventions.

Summary:

The best nursing actions align with the ANA Standards by ensuring cultural competence and patient-family involvement in the care plan.

Correct Answer:  Respiratory rate 10/min

Explanation:

A decreased respiratory rate (respiratory depression) is the most critical finding in opioid toxicity. Opioids suppress the central nervous system (CNS), leading to slow, shallow breathing or even respiratory arrest. A respiratory rate of 10 breaths per minute is abnormally low, indicating opioid-induced respiratory depression, which can be life-threatening and requires immediate intervention.

Why the Other Options Are Incorrect

Temperature 38.2°C (100.8°F)

Fever is not a typical symptom of opioid toxicity. Opioids usually lower body temperature, not raise it. A fever may suggest an infection or another underlying condition rather than opioid overdose.

Heart Rate 112/min

Opioids generally cause bradycardia (slow heart rate), not tachycardia. A high heart rate (tachycardia) may be due to pain, anxiety, or withdrawal, but not toxicity.

Blood Pressure 168/90 mm Hg

Opioid overdose typically causes hypotension (low blood pressure) rather than hypertension. Elevated blood pressure may be due to pain, withdrawal, or another condition, but not opioid toxicity.

Summary

The most concerning and expected finding in opioid toxicity is respiratory depression (respiratory rate 10/min or lower). Other signs include pinpoint pupils, decreased level of consciousness, and hypotension. Immediate intervention, such as administering naloxone (Narcan), is necessary to prevent respiratory failure.