Nokea
A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3ˆ’, 36 mEq/L. The nurse should assess the client for?
- A. Cyanosis.
- B. Flushed skin.
- C. Irritability.
- D. Anxiety.
Correct Answer: C
Rationale: The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2) with adequate oxygenation (PaO2 80). Irritability is a symptom of CO2 retention. Cyanosis requires lower PaO2. Flushed skin and anxiety are less specific.
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A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:
- A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
- B. Administer oxygen via nasal cannula.
- C. Offer pain medication for the chest heaviness.
- D. Inform the physician of the chest heaviness.
Correct Answer: A
Rationale: Assessing the characteristics of chest heaviness clarifies whether it is cardiac (e.g., angina) or non-cardiac, guiding further actions like oxygen or physician notification.
A physician orders vitamin B12 for a client with pernicious anemia. Which site is appropriate for the nurse to administer vitamin B12? Select all that apply.
- A. Deltoid.
- B. Greater femur trochanter.
- C. Acromion muscle.
- D. Ventrogluteal.
- E. Upper back.
- F. Dorsogluteal.
Correct Answer: A,D,F
Rationale: Vitamin B12 is administered intramuscularly, and appropriate sites include the deltoid, ventrogluteal, and dorsogluteal muscles, as these provide adequate muscle mass for absorption. The greater femur trochanter and acromion muscle are not standard injection sites, and the upper back is not suitable for intramuscular injections.
A client with Graves' disease is treated with radioactive iodine (RAI) in the form of sodium iodide 131I. Which of the following statements by the nurse will explain to the client how the drug works?
- A. The radioactive iodine stabilizes the thyroid hormone levels before a thyroidectomy.'
- B. The radioactive iodine reduces uptake of thyroxine and thereby improves your condition.'
- C. The radioactive iodine slows your body's production of thyroid hormones.'
- D. The radioactive iodine destroys thyroid tissue and thyroid hormones are no longer produced.'
Correct Answer: D
Rationale: Radioactive iodine (RAI) works by destroying thyroid tissue, which reduces or eliminates the production of thyroid hormones, treating hyperthyroidism in Graves' disease.
As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which of the following statements by the client indicates she understands her current ability?
- A. I will be able to have sexual intercourse until the urinary catheter is removed.'
- B. I can participate in sexual activity but might not experience orgasm.'
- C. I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay.'
- D. I should be able to participate in sexual activity, but I will be infertile.'
Correct Answer: B
Rationale: Quadriplegia may impair sensation and orgasm but does not preclude sexual activity, which the client correctly understands.
Sensorineural hearing loss results from which of the following conditions?
- A. Presence of fluid and cerumen in the external canal.
- B. Sclerosis of the bones of the middle ear.
- C. Change to the cochlear or vestibulocochlear nerve.
- D. Emotional disturbance resulting in a functional hearing loss.
Correct Answer: C
Rationale: Sensorineural hearing loss results from damage to the cochlear or vestibulocochlear nerve, affecting the inner ear or neural pathways.