Nokea
A client with acute respiratory failure (ARF) may present with which of the following manifestations? (Select one that doesn't apply.)
- A. Severe dyspnea
- B. Decreased level of consciousness
- C. Headache
- D. Nausea
Correct Answer: D
Rationale: In acute respiratory failure (ARF), the body is not getting enough oxygen, leading to respiratory distress. Symptoms of ARF typically include severe dyspnea (difficulty breathing), decreased level of consciousness due to hypoxia, and headache from inadequate oxygenation to the brain. Nausea is not a typical manifestation of ARF and would not be expected in this condition.
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A healthcare professional is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the healthcare professional expect?
- A. HCO3- 30 mEq/L
- B. PaCO2 50 mm Hg
- C. pH 7.45
- D. Potassium 3.3 mEq/L
Correct Answer: B
Rationale: In respiratory acidosis, the primary disturbance is an increase in PaCO2 levels above the normal range of 35-45 mm Hg. Option B, PaCO2 50 mm Hg, indicates an elevated partial pressure of carbon dioxide, which is consistent with respiratory acidosis. Options A, C, and D are not directly indicative of respiratory acidosis. HCO3- (Option A) is more related to metabolic acidosis or alkalosis, pH (Option C) is within the normal range indicating no acid-base imbalance, and potassium (Option D) levels are not specific to respiratory acidosis.
The nurse is educating a G1P0 client who is 34 weeks in the third trimester. gestation and in her third trimester. Which of the
- A. I should gain 3.5 to 5 pounds in the first following educational topics would be appropriate trimester and 1 pound per week in the last two at this time? Select all that apply. trimesters.
- B. Contraception options after delivery
- C. I should gain 10 pounds in the first trimester,
- D. Group B strep (GBS) screen before onset of labor 10 pounds in the second trimester, and 10 pounds
Correct Answer: A
Rationale: I should gain 3.5 to 5 pounds in the first trimester and 1 pound per week in the last two trimesters.
The nurse is assessing a client with ruptured membranes. What finding suggests chorioamnionitis?
- A. Clear amniotic fluid.
- B. Foul-smelling vaginal discharge.
- C. Fetal heart rate of 140 beats/minute.
- D. Absence of maternal fever.
Correct Answer: B
Rationale: Foul-smelling discharge is a key indicator of chorioamnionitis, an infection of the amniotic fluid.
The menstrual phase of the menstrual cycle is characterized by what?
- A. shedding of the endometrial lining
- B. ovulation
- C. fertilization
- D. implantation
Correct Answer: A
Rationale:
A woman delivered a baby 9lbs 10oz 1 hour ago. When you
arrive to perform a 15-minute assessment she tells you that she feels
all wet underneath. You discover that both pads are completely
saturated and that she’s lying in a 6-inch diameter of blood. What
does nurse do first
- A. Assess the fundus for firmness
- B. Change the patient's pads
- C. Notify the provider
- D. Document the findings
Correct Answer: A
Rationale: In this scenario, the priority action for the nurse to take is to assess the source of the woman's feeling of wetness underneath her. This could indicate a significant amount of postpartum bleeding, also known as hemorrhage. It is crucial to determine if she is experiencing excessive bleeding as this can be life-threatening if not addressed promptly. By identifying the source of the wetness, the nurse can assess the situation and take appropriate actions to address any potential complications. Once the severity of bleeding is determined, further assessments and interventions can be initiated accordingly.