Nokea
A nurse assesses a client who is experiencing an acid-base imbalance. The clients arterial blood gas values are pH 7.34, PaO2 88 mm Hg, PaCO2 38 mm Hg, and HCO3 19 mEq/L. Which assessment should the nurse perform first?
- A. . Cardiac rate and rhythm
- B. Skin and mucous membranes
- C. Musculoskeletal strength
- D. Level of orientation
Correct Answer: A
Rationale: The correct answer is A: Cardiac rate and rhythm. In an acid-base imbalance, the pH is below the normal range indicating acidosis. The nurse should assess the cardiac rate and rhythm first because acidosis can have negative effects on the cardiovascular system. Acidosis can lead to arrhythmias and decreased cardiac output. Monitoring the cardiac rate and rhythm is crucial to detect any cardiac complications early. Choices B, C, and D are not the priority in this situation as they are not directly impacted by acid-base imbalances.
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A nurse assesses a client who has a radial artery catheter. Which assessment should the nurse complete first?
- A. . Amount of pressure in fluid container
- B. Date of catheter tubing change
- C. Percent of heparin in infusion container
- D. . Presence of an ulnar pulse
Correct Answer: D
Rationale: The correct answer is D: Presence of an ulnar pulse. This is the most important assessment to complete first because the presence of an ulnar pulse indicates adequate circulation in the hand, ensuring that the radial artery catheter is not compromising blood flow. If the ulnar pulse is absent, it may signify impaired circulation and potential complications such as ischemia.
Choice A is incorrect because the amount of pressure in the fluid container is not directly related to the assessment of the radial artery catheter.
Choice B is incorrect because the date of catheter tubing change is important for infection control but not the immediate priority in this situation.
Choice C is incorrect as the percent of heparin in the infusion container is important for anticoagulation therapy but does not take precedence over assessing circulation in the hand.
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the clients chart prior to administering the medication: Client: Thomas Jackson DOB: 5/3/1936 Gender: Male January 23 (Today): Right uppe
- A. Notify the health care provider
- B. . Administer the prescribed medication.
- C. Discontinue the PICC
- D. Switch the medication to the oral route
Correct Answer: B
Rationale: The correct answer is B: Administer the prescribed medication. The nurse has assessed the client's site and reviewed the chart, indicating readiness to administer the medication. It is crucial to follow the healthcare provider's order and administer the prescribed medication as planned. Notifying the provider (A) is unnecessary if all assessments are normal. Discontinuing the PICC line (C) without a valid reason can lead to complications. Switching to oral route (D) should only be considered if there are specific contraindications for the intravenous route. It's important to prioritize safe and effective medication administration based on the client's condition and healthcare provider's orders.
The ICU nurse is caring for a patient who experienced trauma in a workplace accident. The patient is complaining
of having trouble breathing with abdominal pain. An ABG reveals the following results: pH
7.28, PaCO2 50 mm Hg, HCO3 23 mEq/L. The nurse should recognize the likelihood of what acidbase disorder?
- A. Respiratory acidosis
- B. Metabolic alkalosis
- C. Respiratory alkalosis
- D. Mixed acidbase disorder
Correct Answer: D
Rationale: The correct answer is D: Mixed acid-base disorder. The ABG results show a pH within the acidic range (7.28), indicating acidosis. The PaCO2 is elevated (50 mm Hg), suggesting respiratory acidosis as the primary disorder. However, the HCO3 level is within normal range (23 mEq/L), which is not consistent with compensatory metabolic alkalosis. Therefore, the presence of both respiratory acidosis and normal HCO3 levels indicates a mixed acid-base disorder.
Choice A (Respiratory acidosis) is incorrect because although the patient has an elevated PaCO2, the normal HCO3 level rules out a pure respiratory acidosis. Choice B (Metabolic alkalosis) and C (Respiratory alkalosis) are incorrect as the ABG results do not support these diagnoses.
You are caring for a patient admitted with a diagnosis of acute kidney injury. When you review your patients most recent laboratory reports, you note that the patients magnesium levels are high. You should prioritize assessment for which of the followin
- A. Diminished deep tendon reflexes
- B. Tachycardia
- C. Cool, clammy skin
- D. Acute flank pain
Correct Answer: A
Rationale: Step 1: High magnesium levels can lead to hypermagnesemia, which can cause decreased neuromuscular function.
Step 2: Diminished deep tendon reflexes are a sign of neuromuscular impairment, indicating potential hypermagnesemia.
Step 3: Assessing for diminished deep tendon reflexes is crucial to monitor neuromuscular function in patients with high magnesium levels.
Summary: A is correct because hypermagnesemia affects neuromuscular function. B, C, and D are incorrect as they do not directly relate to the effects of high magnesium levels.
1.A nurse prepares to insert a peripheral venous catheter in an older adult client. Which action should the nurse take to protect the clients skin during this procedure?
- A. Lower the extremity below the level of the heart.
- B. Apply warm compresses to the extremity.
- C. Tap the skin lightly and avoid slapping.
- D. Place a washcloth between the skin and tourniquet
Correct Answer: D
Rationale: The correct answer is D: Place a washcloth between the skin and tourniquet. This step helps protect the client's skin by providing a barrier between the tourniquet and the skin, reducing the risk of skin irritation or damage. Lowering the extremity below the heart (A) can increase venous pressure and make it harder to insert the catheter. Warm compresses (B) can dilate blood vessels and increase the risk of bruising. Tapping the skin lightly (C) can irritate the skin and is unnecessary for skin protection.