Nokea
A client with a pyloric obstruction is admitted to the hospital with vomiting. Which of the following blood gases would the nurse expect to see in the client with vomiting?
- A. $\mathrm{pH} 7.33, \mathrm{PCO}_2 30 \mathrm{~mm} \mathrm{Hg}$
- B. $\mathrm{pH} 7.50, \mathrm{PCO}_2 32 \mathrm{~mm} \mathrm{Hg}$
- C. $\mathrm{pH} 7.30, \mathrm{PCO}_2 50 \mathrm{~mm} \mathrm{Hg$
- D. $\mathrm{pH} 7.47, \mathrm{PCO}_2 40 \mathrm{~mm} \mathrm{Hg}$
Correct Answer: B
Rationale: Vomiting causes loss of hydrochloric acid, leading to metabolic alkalosis, indicated by a high pH (7.50) and normal to low PCO2.
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The nurse is reinforcing teaching for a client with atrial fibrillation who has a new prescription for warfarin. Which of the following statements by the client would require follow-up?
- A. I will avoid taking over-the-counter aspirin.'
- B. I must avoid consuming green, leafy vegetables such as spinach and kale.'
- C. I should avoid consuming any caffeinated products.'
- D. I will talk with my health care provider before taking any nutritional supplements.'
Correct Answer: B
Rationale: Avoiding all green leafy vegetables (B) is incorrect; consistent intake is needed to maintain stable INR. Avoiding aspirin (A), caffeine (C), and consulting about supplements (D) are correct.
The home health nurse visits a 72-year-old client with pneumonia who was discharged from the hospital 3 days ago. The client has less of a productive cough at night but now reports sharp chest pain with inspiration. Which finding is most important for the nurse to report to the supervising registered nurse?
- A. Bronchial breath sounds
- B. Increased tactile fremitus
- C. Low-pitched wheezing (rhonchi)
- D. Pleural friction rub
Correct Answer: D
Rationale: Pleural friction rub (D) indicates pleuritis or pleural effusion, a serious complication requiring immediate reporting. Other findings (A, B, C) are less specific or urgent.
The nurse has reinforced teaching with a client with newly diagnosed polycythemia vera. Which of the following statements by the client would require follow-up?
- A. I should take an iron supplement daily.'
- B. I should increase my daily fluid intake.'
- C. I may require frequent phlebotomy.'
- D. I will take a low-dose aspirin daily.'
Correct Answer: A
Rationale: Iron supplements (A) can worsen polycythemia vera by increasing red blood cell production, requiring follow-up. Increased fluids (B), phlebotomy (C), and aspirin (D) are appropriate.
The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which finding requires intervention by the nurse?
- A. Contraction duration of 95 seconds
- B. Contraction frequency of every 3 minutes
- C. Contraction intensity of 45 mm Hg
- D. Uterine resting tone of 10 mm Hg
Correct Answer: A
Rationale: Contraction duration of 95 seconds (A) is too long and may reduce fetal oxygenation, requiring intervention. Frequency (B), intensity (C), and resting tone (D) are within normal limits.
The nurse is caring for a client who is experiencing an acute exacerbation of asthma. Which of the following medications should the nurse administer to the client? Select all that apply.
- A. albuterol
- B. buproten
- C. ipratropium
- D. tobramycin
- E. montelukast
Correct Answer: A, C
Rationale: Albuterol (A) and ipratropium (C) are bronchodilators used in acute asthma exacerbations. Ibuprofen (B), tobramycin (D), and montelukast (E) are not indicated for acute management.