Brain Melters
In this acid-base imbalance, hydrogen ions move out of cells while potassium shifts in—leading to a drop in serum potassium levels, or hypokalemia.
Answer: What is alkalosis?
Early signs such as restlessness and irritability occur as the brain reacts to low oxygen levels in the blood.
Answer: What is hypoxemia?
COPD and jugular vein distention (JVD) are both associated with this condition, in which chronic lung disease leads to right-sided heart failure.
Answer: What is cor pulmonale?
A patient receiving chemotherapy has an ANC of 400/mm³. Which nursing intervention is the priority?
A. Encourage fresh fruit intake
B. Place the patient in a private room
C. Limit fluid intake
D. Administer vaccines
B. Place the patient in a private room ✅
Rationale:
An ANC <500 indicates severe neutropenia and extremely high infection risk. Priority is protective (neutropenic) precautions, including a private room. Fresh fruits may carry bacteria, vaccines (especially live) are contraindicated, and fluid restriction is unrelated.
A hypertensive crisis can cause this serious complication, presenting with symptoms like slurred speech, facial droop, and weakness on one side of the body.
Answer: What is a stroke?
A client’s ABG results are:
pH: 7.31, PaCO₂: 30 mm, HgHCO₃: 16 mEq/L
These values indicate this acid-base status.
Answer: What is partially compensated metabolic acidosis?
Before starting a procedure, this essential step ensures the patient understands what will happen and can help reduce anxiety.
Answer: What is patient education?
The nurse may administer oxygen, albuterol, methylprednisolone, and IV fluids to treat this acute respiratory condition characterized by inflammation, bronchoconstriction, and low oxygen levels.
Answer: What is an asthma exacerbation with hypoxia?
In which situation should a nurse check the pedal pulses? Symptoms may include intermittent claudication, leg pain during activity, numbness, cool skin, and slow-healing wounds.
Answer: What is peripheral artery disease (PAD)?
A patient with HIV has a CD4 count of 180 cells/mm³. What is the nurse’s priority concern?
A. Risk for opportunistic infection
B. Risk for fluid overload
C. Risk for hypoglycemia
D. Risk for hypertension
A. Risk for opportunistic infection ✅
B. Risk for fluid overload
C. Risk for hypoglycemia
D. Risk for hypertension
Rationale:
A CD4 count <200 defines AIDS and indicates severe immunosuppression. The greatest risk is opportunistic infections (e.g., PCP pneumonia).
When a patient’s oxygen saturation or PaO₂ drops into the 50s, this is the nurse’s immediate action.
Answer: What is administering oxygen?
Late manifestations include cool clammy skin, cyanosis, hypotension, coma, combativeness, dyspnea at rest, pause for breath between sentences or words, retractions, accessory muscle use, and intercoastal retractions.
What is hypoxia?
To prevent future asthma exacerbations, clients are taught to identify and avoid these environmental or situational factors that can worsen their condition.
Answer: What are irritants or precipitating factors?
Slow capillary refill in the lower extremities is a common sign of this condition characterized by poor blood flow and intermittent claudication.
Answer: What is peripheral artery disease (PAD)?
(Select All That Apply)
Which interventions are appropriate for a patient with neutropenia?
☐ Avoid raw fruits and vegetables
☐ Perform frequent hand hygiene
☐ Limit visitors with illness
☐ Administer live vaccines
☐ Monitor temperature regularly
(Select All That Apply)
Which interventions are appropriate for a patient with neutropenia?
☑ Avoid raw fruits and vegetables
☑ Perform frequent hand hygiene
☑ Limit visitors with illness
☐ Administer live vaccines
☑ Monitor temperature regularly
Rationale:
Neutropenic precautions aim to reduce infection exposure:
Avoid raw foods (bacteria risk)
Strict hand hygiene
Limit sick contacts
Monitor for fever (early infection sign)
Live vaccines are contraindicated.
To compensate for metabolic alkalosis, the respiratory system responds by doing this to retain carbon dioxide and increase acidity in the blood.
Answer: What is slowing the breathing rate or hypoventilating?
Especially in older adults or those with weakened immune systems, this mental status change is often an early and common sign of infections such as pneumonia, UTI, influenza, or C. difficile.
Answer: What is confusion?
This life-threatening condition is a severe asthma attack that does not respond to typical rescue inhaler treatment.
Answer: What is status asthmaticus?
A patient is prescribed prednisone long-term. Which effect should the nurse monitor for?
A. Increased immune response
B. Suppressed inflammation
C. Increased white blood cell destruction
D. Enhanced antibody production
B. Suppressed inflammation ✅
Rationale:
Prednisone is a corticosteroid that suppresses inflammation and immune response, increasing infection risk. It does not enhance immunity.
(Select All That Apply) Which findings indicate immunosuppression?
☐ Frequent infections
☐ Delayed wound healing
☐ Fever
☐ Leukopenia
☐ Rapid recovery from illness
Which findings indicate immunosuppression?
☑ Frequent infections
☑ Delayed wound healing
☐ Fever
☑ Leukopenia
☐ Rapid recovery from illness
Rationale:
Immunosuppression leads to:
Increased infections
Poor healing
Low WBC count (leukopenia)
Fever may be absent or blunted, and rapid recovery is not expected.
Patients is at risk for metabolic acidosis because this conditions causes a loss base from the body.
Answer: Who are patients with diarrhea losing bicarbonate?
Because of the increased work of breathing, patients with this chronic respiratory condition may need up to 4,000 calories a day—and should receive high-protein foods between meals.
Answer: What is COPD (Chronic Obstructive Pulmonary Disease)?
This respiratory device, commonly used to deliver albuterol in conditions like COPD and pneumonia, turns liquid medication into a fine mist—but was avoided during COVID-19 due to the risk of aerosolizing the virus.
Answer: What is a nebulizer?
This process involves plaque buildup narrowing arteries, raising blood pressure, and contributing to peripheral artery disease by reducing blood flow to the limbs.
Answer: What is atherosclerosis?
When a patient’s oxygen saturation falls below 90%, this simple nursing action helps improve oxygenation by aiding lung expansion and should be done before giving oxygen.
Answer: What is raising the head of the bed?