Nokea
A client has had diarrhea for the past 3 days. Which acid/base imbalance would the nurse expect the client to have?
- A. Respiratory alkalosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: Prolonged diarrhea leads to loss of bicarbonate, causing metabolic acidosis.
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The client is being evaluated for possible acute leukemia. Which inquiry by the nurse is most important?
- A. Have you noticed a change in sleeping habits recently?
- B. Have you had a respiratory infection in the last 6 months?
- C. Have you lost weight recently?
- D. Have you noticed changes in your alertness?
Correct Answer: C
Rationale: Unexplained weight loss is a common symptom of leukemia due to increased metabolic demand and systemic effects of the disease.
A 28-year-old woman pregnant with twins comes in for her prenatal appointment. She tells the nurse that she has two children at home (ages 4 years and 16 months), and she had one abortion 6 years ago when she was 8 weeks along in the pregnancy. The nurse charts
- A. gravida 4, para 2.
- B. gravida 4, para 3.
- C. gravida 5, para 2.
- D. gravida 5, para 3.
Correct Answer: C
Rationale: Gravida counts all pregnancies (2 children, 1 abortion, current twin pregnancy = 5). Para counts deliveries after 20 weeks (2 children = 2). Twins count as one delivery.
Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
- A. A cephalhematoma
- B. Molding
- C. Subdural hematoma
- D. Caput succedaneum
Correct Answer: A
Rationale: A cephalhematoma is a subperiosteal hemorrhage that does not cross suture lines, commonly seen in newborns.
An older man is seen in the outpatient clinic for treatment of an acute attack of gout. Which of the following nursing interventions would be MOST beneficial in decreasing the client’s pain during ambulation?
- A. Perform passive range-of-motion exercises before walking.
- B. Encourage partial weight bearing while ambulating.
- C. Immobilize the extremity between activities.
- D. Restrict the amount of time and the distance the man walks.
Correct Answer: B
Rationale: would relieve weight, pressure, and stress on affected leg, may use walker
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: Eschar covering the wound bed makes it unstageable, as the depth cannot be assessed until debridement.