Nokea
A client is admitted to the medical unit with acute pancreatitis. While planning care for this client, the nurse will include which of the following interventions? (Select all that apply).
- A. Administer antiemetics as needed.
- B. Administer analgesics as needed.
- C. NPO (nothing by mouth) until pain-free.
- D. Monitor blood glucose and provide insulin as needed.
- E. Side-lying or fetal position.
- F. Monitor hydration status.
Correct Answer: A,B,C,D,F
Rationale: These interventions address pain management, pancreatic rest, glucose control, and hydration in acute pancreatitis.
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A nurse is reviewing the arterial blood gas (ABG) values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?
- A. pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg
- B. pH 7.50, HCO3- 20 mEq/L, PaCO2 32 mm Hg
- C. pH 7.55, HCO3- 30 mEq/L, PaCO2 31 mm Hg
- D. pH 7.30, HCO3- 26 mEq/L, PaCO2 50 mm Hg
Correct Answer: A
Rationale: The values indicate metabolic acidosis with compensatory respiratory alkalosis, typical in CKD due to impaired acid excretion.
A nurse is assessing a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure?
- A. Tachypnea
- B. Hypotension
- C. Decreased level of consciousness
- D. Bilateral weakness of extremities
Correct Answer: C
Rationale: Decreased LOC is the earliest and most sensitive sign of increased ICP.
A client is admitted to the emergency department after sustaining multiple rib fractures in a motor vehicle accident. Upon assessment, the nurse notes that the client has flail chest. Which of the following signs and symptoms are associated with this condition? (Select all that apply.)
- A. Bradycardia
- B. Anxiety
- C. Dyspnea
- D. Unequal chest expansion
- E. Hypotension
- F. Paradoxical chest movement
Correct Answer: B,C,D,E,F
Rationale: Flail chest causes respiratory distress, paradoxical movement, and can lead to shock.
The nurse is assessing for asterixis in a client with cirrhosis. How should the nurse assess for asterixis?
- A. Instruct the client to lean forward.
- B. Ask the client to extend the arms.
- C. Dorsiflex the client's foot.
- D. Measure the abdominal girth.
Correct Answer: B
Rationale: Asterixis (liver flap) is assessed by having patient extend arms and observing for involuntary flapping motions.
A nurse is teaching an ACLS class and is discussing heart rhythms and treatment. Which of the following rhythms would indicate the need for defibrillation?
- A. Atrial fibrillation
- B. Supraventricular tachycardia
- C. Asystole
- D. Ventricular fibrillation
Correct Answer: D
Rationale: Ventricular fibrillation is a life-threatening rhythm requiring immediate defibrillation.