Nokea
A 35-year-old client is admitted to the hospital with diabetic ketoacidosis. Results of arterial blood gases are pH 7.2, PaO2 90, PaCO2 45, and HCO3 16. The nursing assessment of arterial blood gases indicate the presence of:
- A. Respiratory alkalosis
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Metabolic acidosis
Correct Answer: D
Rationale: Metabolic acidosis is determined by low pH and HCO3.
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The client with a history of heart failure is prescribed spironolactone (Aldactone). The nurse should monitor for which potential side effect?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypoglycemia
- D. Hypertension
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia by reducing potassium excretion. Hypokalemia is caused by other diuretics, hypoglycemia is unrelated, and spironolactone lowers blood pressure.
A client had a myocardial infarction 5 days ago. His physician has ordered an echocardiogram to determine how his myocardial infarction has affected his ventricular wall motion. When the client asks if this test is painful, an appropriate response is:
- A. No, but you must be able to ride on a stationary bicycle while the test is being performed.
- B. No, but you will have to lie still and the gel that is used may be cool.
- C. Yes, but your physician will be there and will order pain medicine for you.
- D. Your physician has ordered medicine, which you will be given before you go for the test, which will make you sleepy.
Correct Answer: B
Rationale: An echocardiogram is non-invasive, requiring the client to lie still while cool gel is applied for ultrasound imaging, with no pain involved.
A client with a history of a stroke is receiving Plavix (clopidogrel). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Hypoglycemia
- D. Fever
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk, requiring monitoring for signs like bruising or epistaxis. Hypertension, hypoglycemia, and fever are not primary concerns.
A 10-year-old client with a pin in the right femur is immobilized in traction. He is exhibiting behavioral changes including restlessness, difficulty with problem solving, inability to concentrate on activities, and monotony. Which of the following nursing implementations would be most effective in helping him cope with immobility?
- A. Providing him with books, challenging puzzles, and games as diversionary activities
- B. Allowing him to do as much for himself as he is able, including learning to do pin-site care under supervision
- C. Having a volunteer come in to sit with the client and to read him stories
- D. Stimulating rest and relaxation by gentle rubbing with lotion and changing the client's position frequently
Correct Answer: B
Rationale: Self-care is usually well received by the child, and it is one of the most useful interventions to help the child cope with immobility, providing a sense of control.
A client with a history of asthma is admitted with complaints of wheezing. The nurse should give priority to:
- A. Administering bronchodilators
- B. Monitoring blood pressure
- C. Administering pain medication
- D. Monitoring temperature
Correct Answer: A
Rationale: Bronchodilators relieve wheezing in asthma by relaxing airway smooth muscles, improving airflow.