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A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived, shown below. Which finding should the nurse report to the physician?
- A. PaCO2.
- B. HCO3.
- C. PaO2.
- D. pH
Correct Answer: A
Rationale: The normal range for partial pressure of arterial carbon dioxide (PaCO2) is 35 to 45 mm Hg. Thus, this client’s PaCO2 level is low. The client is experiencing respiratory alkalosis (carbonic acid defi cit) due to hyperventilation. The nurse should report this fi nding to the physician because it requires intervention. The increase in ventilation decreases the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35 to 7.45; in uncompensated respiratory alkalosis, the serum pH is greater than 7.45.
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Which nursing intervention is most important in preventing septic shock?
- A. Administering I.V. fluid replacement therapy as ordered.
- B. Obtaining vital signs every 4 hours for all clients.
- C. Monitoring red blood cell counts for elevation.
- D. Maintaining asepsis of indwelling urinary catheters.
Correct Answer: D
Rationale: Septic shock is often caused by infections from invasive devices like urinary catheters. Maintaining asepsis during catheter insertion and care is critical to prevent infection and subsequent septic shock. Fluid therapy, vital signs, and RBC monitoring are important but not primary for prevention.
A 62-year-old Chinese man is admitted with multiple injuries from a motor vehicle accident. He complains of severe pain and requests frequent medication. One of the assistive nursing personnel expresses surprise, saying, "I thought Asian people were very stoic about pain." Which is the nurse's best response about pain?
- A. Expression and perception of pain vary widely from person to person.
- B. Tolerance of pain is the same in all people.
- C. Tolerance of pain is determined by a person's genetic makeup.
- D. Pain perception is the same in all people.
Correct Answer: A
Rationale: Pain expression and perception vary individually due to cultural, personal, and situational factors, countering the stereotype. Pain tolerance and perception are not uniform or solely genetic.
The nurse is caring for a client with cancer experiencing chronic pain and episodes of breakthrough pain. Which prescription should the nurse request from the primary healthcare provider (PHCP) to provide effective pain control?
- A. Hydromorphone via patient-controlled analgesia (PCA)
- B. Morphine intramuscular (IM) as needed (PRN) for pain
- C. Oxycodone extended-release (ER) by mouth (PO)
- D. Ketorolac via intravenous (IV) push
Correct Answer: A
Rationale: Hydromorphone via PCA allows for both continuous and patient-controlled dosing, ideal for managing chronic cancer pain with breakthrough episodes.
To ensure safety for a hospitalized blind client, the nurse should:
- A. Require that the client has a sitter for each shift.
- B. Require that the client stays in bed until the nurse can assist.
- C. Orient the client to the room environment.
- D. Keep the side rails up when the client is alone.
Correct Answer: C
Rationale: Orienting the client to the room environment promotes safety by helping the blind client navigate the space independently and reduce the risk of falls.
During an initial assessment of a client diagnosed with vasospastic disorder (Raynaud's phenomenon), the nurse notes a sudden color change to white in the fingers. The nurse should first assess:
- A. Appearance of cyanosis
- B. Radial pulse
- C. SpO2 of the affected fingers
- D. Blood pressure
Correct Answer: B
Rationale: A sudden color change to white in Raynaud's indicates vasospasm. Assessing the radial pulse first confirms whether blood flow is present despite the vasospasm, guiding further action. Cyanosis, SpO2, and blood pressure are secondary, as pulse assessment is more immediate and specific.