Nokea
A client is postoperative with shallow respirations at 9/min. Which acid-base imbalance should the nurse identify the client as being at risk for developing initially?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: The correct answer is A: Respiratory acidosis. Shallow respirations at 9/min indicate hypoventilation, leading to retention of CO2 and respiratory acidosis. This is because inadequate removal of CO2 results in an increase in carbonic acid concentration, leading to a decrease in blood pH. Respiratory alkalosis (B) is unlikely with shallow respirations. Metabolic acidosis (C) results from nonrespiratory factors. Metabolic alkalosis (D) is not related to respiratory rate.
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For the evaluation feedback process to be effective, the medical-surgical nurse who is a manager
- A. conducts weekly meetings with staff members.
- B. considers staff members' interests and abilities when delegating tasks.
- C. provides goals for staff members to meet.
- D. informs staff members regularly of how well they are performing their jobs.
Correct Answer: D
Rationale: Regular feedback helps staff understand their performance and areas for improvement.
A client's arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The client is experiencing which of the following acid-base imbalances?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: C
Rationale: The correct answer is C: Respiratory acidosis. In this case, the low pH indicates acidosis, and the elevated PaCO2 indicates respiratory involvement. In respiratory acidosis, the lungs cannot eliminate enough CO2, leading to an increase in carbonic acid and a decrease in pH. Metabolic acidosis (choice A) would involve a primary decrease in bicarbonate levels, not seen in this scenario. Metabolic alkalosis (choice B) would involve an increase in bicarbonate levels, which is not indicated by the given information. Respiratory alkalosis (choice D) would have a low PaCO2 and an elevated pH, opposite of what is seen here.
Which triage assessment prioritizes the client’s need for treatment as the need to be seen now?
- A. Delayed
- B. Immediate
- C. Minimal
- D. Expectant
Correct Answer: B
Rationale: The correct answer is B because immediate triage indicates the client requires urgent treatment.
When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?
- A. Insert an oral airway
- B. Administer the abdominal thrust maneuver
- C. Turn the client to the side
- D. Perform a blind finger sweep
Correct Answer: B
Rationale: The correct action is to administer the abdominal thrust maneuver (Heimlich maneuver) first to attempt to dislodge the foreign body. This is the priority intervention when a conscious client is experiencing airway obstruction. Inserting an oral airway (Choice A) may worsen the obstruction. Turning the client to the side (Choice C) does not directly address the airway obstruction. Performing a blind finger sweep (Choice D) is not recommended as it can push the object further down the airway. Administering the abdominal thrust maneuver is the most effective and safest initial intervention to clear the airway obstruction.
When caring for a dying client, which intervention protects the client’s skin from breakdown?
- A. Applying oil to the client’s body.
- B. Providing plenty of drinking water to hydrate the client’s skin.
- C. Giving the client a sponge bath twice a day.
- D. Changing the client’s position every 2 hours.
Correct Answer: D
Rationale: Regularly repositioning the client reduces pressure on vulnerable areas, preventing skin breakdown.