Nokea
What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36 mmHg, and HCO3 24 mEq/L?
- A. metabolic alkalosis
- B. homeostasis
- C. respiratory acidosis
- D. respiratory alkalosis
Correct Answer: B
Rationale: These ABG values are within normal limits. Choices A, C, and D are incorrect because the ABG values indicate none of these acid-base disturbances.
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Which of the following observations is most important when assessing a client's breathing?
- A. presence of breathing and pulse rate
- B. breathing pattern and adequacy of breathing
- C. presence of breathing and adequacy of breathing
- D. patient position and adequacy of breathing
Correct Answer: C
Rationale: Ensuring the presence and adequacy of breathing is critical, as adequate oxygenation is essential for life. Pulse rate and position are secondary considerations.
A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:
- A. within normal limits, so a weight-reduction diet is unnecessary.
- B. lower than normal, so education about nutrient-dense foods is needed.
- C. indicating obesity because the BMI is 35.
- D. indicating overweight status because the BMI is 27.
Correct Answer: C
Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. It is calculated by utilizing a chart or nomogram that plots height and weight. This client's BMI is 35, indicating obesity. Goals of diet therapy are aimed at decreasing weight and increasing activity to healthy levels based on a client's BMI, activity status, and energy requirements.
When assessing a client with early impairment of oxygen perfusion, such as pulmonary embolus, the nurse should expect to find restlessness and which of the following symptoms?
- A. warm, dry skin
- B. bradycardia
- C. tachycardia
- D. eupnea
Correct Answer: C
Rationale: The cardinal signs of respiratory problems and hypoxia are restlessness, diaphoresis, tachycardia, and cool skin. Bradycardia might occur much later in the process when the condition is severe. Eupnea is normal respirations in rate and depth.
When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:
- A. When started, therapy must not be interrupted to prevent viral resistance
- B. When started, therapy must not be interrupted to prevent opportunistic infection
- C. Therapy should be interrupted for one day each month to prevent toxicity
- D. Therapy should be interrupted for one week every three months to prevent toxicity
Correct Answer: A
Rationale: HIV mutates very rapidly, and any interruption of therapy can allow viral resistance to emerge - even taking a dose late. Choice B is incorrect because, when the virus is kept in check with anti-retrovirals, the client's own immune system is able to keep opportunistic infections at bay. Choices C and D are incorrect because therapy should not be interrupted for any reason. If the client develops toxicity, another anti-retroviral drug might be prescribed.
Laboratory tests reveal the following electrolyte values for Mr. Smith: Na 135 mEq/L, Ca 8.5 mg/dL, Cl 102 mEq/L, and K 2.0 mEq/L. Which of the following values should the nurse report to the physician because of its potential risk to the client?
- A. Ca
- B. K
- C. Na
- D. Cl
Correct Answer: B
Rationale: A potassium level of 2.0 mEq/L is critically low (normal 3.5-5.5 mEq/L), risking cardiac arrhythmias, and should be reported immediately.