Nokea
A client is at risk for development of metabolic alkalosis because of persistent vomiting. The nurse should assess the client specifically for:
- A. Irritability.
- B. Hyperventilation.
- C. Diarrhea.
- D. Edema.
Correct Answer: B
Rationale: Persistent vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, which can manifest as hyperventilation as the body compensates for elevated pH.
You may also like to solve these questions
A client has a prescription to have a set of arterial blood gases (ABGs) drawn, and the intended site is the radial artery. The nurse ensures that which is positive before the ABGs are drawn?
- A. Allen test
- B. Turner's sign
- C. Babinski reflex
- D. Brudzinski's sign
Correct Answer: A
Rationale: The Allen test is performed before drawing ABGs. Both the radial and ulnar arteries are occluded and then pressure on the ulnar artery is released. Observation is made in the distal circulation. If the results are positive, then the client has adequate circulation and the radial artery may be used. Turner's sign is the bluish discoloration of the flanks and is indicative of pancreatitis. The Babinski reflex is checked by stroking upward on the sole of the foot. Brudzinski's sign tests for nuchal rigidity by bending the head down toward the chest.
A client has a history of fibrocystic disorder of the breasts. The nurse determines that the client understands the nature of the disorder when the client states that symptoms are most likely to occur at which time?
- A. After menses
- B. Before menses
- C. In the spring months
- D. In the winter months
Correct Answer: B
Rationale: Fibrocystic breast disorder is characterized by cyclical breast pain and tenderness due to hormonal fluctuations, with symptoms most pronounced before menses when estrogen levels peak, leading to breast tissue swelling and cyst formation. Symptoms typically subside after menses. Seasonal changes, such as spring or winter months, do not influence fibrocystic breast symptoms.
Which of the following is NOT an essential component of a restraint order?
- A. Informed consent for the restraint
- B. The reason for the restraint
- C. The type of restraint to be used
- D. Client behaviors that necessitated the restraints
Correct Answer: A
Rationale: A restraint order requires the reason , type , and client behaviors necessitating the restraint . Informed consent is not typically required for restraints, as they are used in emergencies or for safety.
A client with a history of type 1 diabetes is admitted with hyperglycemia. The nurse should include which of the following in the plan of care?
- A. Administer regular insulin as prescribed.
- B. Restrict fluid intake.
- C. Encourage a high-carbohydrate diet.
- D. Administer glucagon.
Correct Answer: A
Rationale: Regular insulin corrects hyperglycemia in type 1 diabetes.
The nurse recognizes that a client with pain disorder is improving when the client says which of the following?
- A. I need to have a good cry about all the pain I've been in and then not dwell on it.'
- B. I need to find another physician who can accurately diagnose my condition.'
- C. The pain medicine that you gave me helps me to relax.'
- D. I'm angry with all of the doctors I've seen who don't know what they're doing.'
Correct Answer: A
Rationale: Expressing a desire to process emotions and move forward indicates improved coping, a sign of progress in managing pain disorder.