Nokea
A client's blood gasses are as follows: pH=7.32, pCO2=62, HCO3=30, and pO2=62. The best interpretation is that the client has which of the following?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: Low pH and high pCO2 indicate respiratory acidosis, likely from CO2 retention, with HCO3 compensating.
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The nurse is doing a pain assessment on the client who has chronic back pain. Which assessment is of greatest value?
- A. Observe the client for grimaces, flinching, and other signs of pain.
- B. Monitor the client's blood pressure.
- C. Ask the client to rate his pain on a scale of 1 to 10.
- D. Monitor the client's pulse and respirations.
Correct Answer: C
Rationale: Self-reported pain rating (1-10 scale) is the most reliable indicator of pain intensity, guiding treatment effectively.
The nurse is caring for a client with a history of atrial fibrillation who is receiving amiodarone (Cordarone) 200 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue
- B. Dry cough and shortness of breath
- C. Occasional palpitations
- D. Mild nausea
Correct Answer: B
Rationale: Dry cough and shortness of breath suggest pulmonary toxicity, a serious amiodarone side effect. Options A, C, and D are less urgent: fatigue and nausea are common, and palpitations are expected in atrial fibrillation.
The nurse is assigned to a client who has heart failure. During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
- A. Take the client's vital signs
- B. Place the client in a sitting position with legs dangling
- C. Contact the health care provider
- D. Administer the PRN antianxiety agent
Correct Answer: B
Rationale: Place the client in a sitting position with legs dangling. This reduces venous return, alleviating pulmonary edema symptoms.
A client who has overdosed on a large quantity of diazepam (Valium).
Which of the following nursing actions should take priority during the first several days of this client's inpatient treatment?
- A. Complete a full psychiatric assessment.
- B. Get in touch with the client's family to involve them in treatment.
- C. Observe and record vital signs frequently, including neurological symptoms.
- D. Determine whether this client may need long-term therapy after this hospitalization.
Correct Answer: C
Rationale: Strategy: Think Maslow. (1) psychosocial, can be done after the client has been medically stabilized (2) psychosocial, can be done after the client has been medically stabilized (3) correct-physical, because of potentially life-threatening complications of depressant overdose such as respiratory failure, pulmonary edema, and seizures, nurse's priority is observation and documentation of vital signs (4) psychosocial, can be done after the client has been medically stabilized
The nurse is administering a tuberculin skin test. How should the nurse insert the needle when administering the skin test?
- A. At a 10-degree angle
- B. At a 30-degree angle
- C. At a 60-degree angle
- D. At a 90-degree angle
Correct Answer: A
Rationale: A tuberculin skin test requires intradermal injection at a 10-degree angle to form a wheal under the skin. Other angles are used for subcutaneous or intramuscular injections.