Nokea
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg; PaCO2, 28 mm Hg; HCO3ˆ’, 24 mEq/L. The nurse determines that which of the following is a possible cause for these findings?
- A. Chronic obstructive pulmonary disease (COPD).
- B. Diabetic ketoacidosis with Kussmaul's respirations.
- C. Myocardial infarction.
- D. Pulmonary embolus.
Correct Answer: D
Rationale: The ABG shows respiratory alkalosis (high pH, low PaCO2) and severe hypoxia (PaO2 50). Pulmonary embolus causes hypoxia and hyperventilation, matching these findings. COPD causes CO2 retention. Ketoacidosis causes metabolic acidosis. Myocardial infarction is less likely to cause this pattern.
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A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first?
- A. Stabilize the leg with Buck's traction.
- B. Apply an ice pack to the affected hip.
- C. Position the client toward the opposite side of the hip.
- D. Notify the orthopedic surgeon.
Correct Answer: D
Rationale: Notifying the surgeon is the priority, as dislocation requires urgent medical intervention.
A priority in the first 24 hours after a bilateral adrenalectomy is:
- A. Beginning oral nutrition.
- B. Promoting self-care activities.
- C. Preventing adrenal crisis.
- D. Ambulating in the hallway.
Correct Answer: C
Rationale: Preventing adrenal crisis is critical post-adrenalectomy due to sudden loss of adrenal hormone production, requiring steroid replacement.
The client with Ménière'sdisease is instructed to modify his diet. The nurse should explain that the most frequently recommended diet modification for the client's disease is:
- A. Low sodium.
- B. High protein.
- C. Low carbohydrate.
- D. Low fat.
Correct Answer: A
Rationale: A low-sodium diet is recommended for Ménière'sdisease to reduce fluid retention in the inner ear, which can decrease the frequency and severity of vertigo attacks.
The nurse is gathering supplies for a transfusion of packed red blood cells (PRBCs). The nurse should obtain which intravenous (IV) fluid to accompany this transfusion?
- A. Lactated Ringers (LR)
- B. 0.9% saline
- C. 0.45% saline
- D. 3% saline
Correct Answer: B
Rationale: 0.9% saline is the only IV fluid compatible with PRBC transfusions, as it does not cause hemolysis or clotting. Lactated Ringer’s, 0.45% saline, and 3% saline can cause red blood cell damage or electrolyte imbalances, making them unsuitable.
A client with Raynaud's phenomenon is prescribed diltiazem (Cardizem). An expected outcome is:
- A. Decreased heart rate
- B. A return to normal sinus rhythm
- C. Reduced episodes of finger numbness
- D. Increased SpO2
Correct Answer: C
Rationale: Diltiazem, a calcium channel blocker, reduces vasospasm in Raynaud's by promoting vasodilation, decreasing episodes of finger numbness. It may lower heart rate or affect rhythm, but these are not primary goals, and SpO2 is not directly improved.