Nokea
A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?
- A. Assess the airway.
- B. Administer prescribed bronchodilators.
- C. Provide oxygen.
- D. Administer prescribed mucolytics
Correct Answer: A
Rationale: The correct answer is A: Assess the airway. The nurse should prioritize airway assessment as the client's ABGs indicate respiratory acidosis (low pH, high PaCO2). This suggests potential airway obstruction or inadequate ventilation. Ensuring a patent airway is crucial for adequate oxygenation. Administering bronchodilators (B) or mucolytics (D) may help with airway clearance but should come after ensuring a clear airway. Providing oxygen (C) is important, but addressing the underlying respiratory acidosis by first assessing the airway is the priority in this situation to prevent further deterioration.
You may also like to solve these questions
A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?
- A. Do you take any over-the-counter medications?
- B. You appear anxious. What is causing your distress?
- C. Do you have a history of anxiety attacks?
- D. You are breathing fast. Is this causing you to feel light-headed?
Correct Answer: B
Rationale: The correct answer is B: "You appear anxious. What is causing your distress?" because hyperventilation can be triggered by emotional distress or anxiety. By addressing the underlying cause of the hyperventilation, the nurse can provide appropriate interventions to help the client manage their anxiety and subsequently reduce the hyperventilation episodes.
A: "Do you take any over-the-counter medications?" - This question is not directly related to addressing the client's anxiety or distress, which is the primary concern in hyperventilation.
C: "Do you have a history of anxiety attacks?" - While relevant to understanding the client's medical history, this question does not address the immediate cause of hyperventilation in this specific situation.
D: "You are breathing fast. Is this causing you to feel light-headed?" - This question focuses on the physical symptoms of hyperventilation rather than exploring the emotional or psychological triggers, which are essential in managing hyperventilation caused by anxiety.
. A nurse is planning care for a nephrology patient with a new nursing graduate. The nurse states, A patient in
renal failure partially loses the ability to regulate changes in pH. What is the cause of this partial inability?
- A. The kidneys regulate and reabsorb carbonic acid to change and maintain pH.
- B. The kidneys buffer acids through electrolyte changes
- C. The kidneys regenerate and reabsorb bicarbonate to maintain a stable pH.
- D. The kidneys combine carbonic acid and bicarbonate to maintain a stable pH.
Correct Answer: C
Rationale: Rationale:
C is correct because in renal failure, the kidneys lose the ability to regenerate and reabsorb bicarbonate, which is essential for maintaining a stable pH level in the body. B is incorrect because the kidneys primarily regulate pH by controlling bicarbonate levels, not through electrolyte changes. A is incorrect because the kidneys do not regulate carbonic acid in the same way. D is incorrect as it does not accurately describe the process of pH regulation in the kidneys.
. A 73-year-old man comes into the emergency department (ED) by ambulance after slipping on a small carpet in his
home. The patient fell on his hip with a resultant fracture. He is alert and oriented; his pupils are equal and reactive to
light and accommodation. His heart rate is elevated, he is anxious and thirsty, a Foley catheter is placed, and 40 mL of
urine is present. What is the nurses most likely explanation for the low urine output?
- A. The man urinated prior to his arrival to the ED and will probably not need to have the Foley catheter kept
in place.
- B. The man likely has a traumatic brain injury, lacks antidiuretic hormone (ADH), and needs vasopressin.
- C. The man is experiencing symptoms of heart failure and is releasing atrial natriuretic peptide that results in
decreased urine output. - D. The man is having a sympathetic reaction, which has stimulated the reninangiotensinaldosterone system that
results in diminished urine output.
Correct Answer: D
Rationale: The correct answer is D. The man's elevated heart rate, anxiety, and low urine output indicate a sympathetic reaction. This reaction stimulates the renin-angiotensin-aldosterone system, leading to decreased urine output. The sympathetic response triggers the release of renin, which activates angiotensin II and aldosterone, causing vasoconstriction and water reabsorption in the kidneys, ultimately reducing urine output. Choice A is incorrect because low urine output is not solely due to urinating before arrival. Choice B is incorrect as there is no indication of traumatic brain injury or ADH deficiency. Choice C is incorrect as atrial natriuretic peptide in heart failure typically increases urine output.
. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to as
- A. Nutritional status
- B. Potassium balance
- C. Calcium balance
- D. Fluid volume status
Correct Answer: D
Rationale: The correct answer is D: Fluid volume status. Assessment of specific gravity helps to determine the concentration of solutes in the urine, indicating the degree of hydration or dehydration. In SIADH, there is water retention leading to diluted urine, resulting in low specific gravity. Monitoring specific gravity every 4 hours is crucial in assessing the patient's fluid volume status and response to treatment.
A: Nutritional status is not directly assessed by specific gravity.
B: Potassium balance is not directly assessed by specific gravity.
C: Calcium balance is not directly assessed by specific gravity.
A nurse in the neurologic ICU has orders to infuse a hypertonic solution into a patient with increased intracranial
pressure. This solution will increase the number of dissolved particles in the patients blood, creating pressure for
fluids in the tissues to shift into the capillaries and increase the blood volume. This process is best described as which
of the following?
- A. Hydrostatic pressure
- B. Osmosis and osmolality
- C. Diffusion
- D. Active transport
Correct Answer: B
Rationale: The correct answer is B: Osmosis and osmolality. When a hypertonic solution is infused, it increases the number of dissolved particles in the blood, creating an osmotic pressure gradient. This causes fluids in the tissues to shift into the capillaries, increasing blood volume. Osmosis is the movement of solvent (water) across a semi-permeable membrane to equalize solute concentrations. Osmolality refers to the concentration of solutes in a solution.
Hydrostatic pressure (choice A) is the force exerted by a fluid against a wall when it is under pressure, not related to the movement of solutes.
Diffusion (choice C) is the movement of solute molecules from an area of high concentration to low concentration, not involving a semi-permeable membrane.
Active transport (choice D) requires energy to move molecules across a membrane against their concentration gradient, not the mechanism described in the scenario.