Nokea
A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?
- A. Diarrhea and vomiting for 36 hours
- B. . Anxiety-induced hyperventilation
- C. Chronic obstructive pulmonary disease (COPD)
- D. Diabetic ketoacidosis and emphysema
Correct Answer: B
Rationale: The correct answer is B: Anxiety-induced hyperventilation. The arterial blood gas values show a pH of 7.48 (alkalosis) with low PaCO2 (respiratory alkalosis), which is consistent with hyperventilation due to anxiety. HCO3 is within normal range, ruling out metabolic causes. A: Diarrhea and vomiting would lead to metabolic acidosis with low pH and decreased HCO3. C: COPD would typically present with respiratory acidosis (high PaCO2) and normal to high HCO3. D: Diabetic ketoacidosis and emphysema would show metabolic acidosis with low pH and low HCO3.
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A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?
- A. Ask family members to speak quietly to keep the client calm.
- B. Assess urine color, amount, and specific gravity each day.
- C. Encourage the client to drink at least 1 liter of fluids each shift.
- D. Dangle the client on the bedside before ambulating.
Correct Answer: D
Rationale: The correct answer is D because dangling the client on the bedside before ambulating helps prevent orthostatic hypotension and potential falls. This step allows the nurse to assess the client's tolerance to changes in position and reduces the risk of injury.
A: Asking family members to speak quietly does not directly address the prevention of injury related to dehydration.
B: Assessing urine parameters is important for monitoring hydration status but does not directly prevent injury.
C: Encouraging fluid intake is important for rehydration but does not directly address the risk of injury during ambulation.
Place a washcloth between the skin and tourniquet
- A. Provide a bed bath instead of letting the client take a shower
- B. Use sterile technique when changing the dressing.
- C. Disconnect the intravenous fluid tubing prior to the clients bath.
- D. Use a plastic bag to cover the extremity with the device
Correct Answer: D
Rationale: The correct answer is D because using a plastic bag to cover the extremity with the device helps to keep the area dry when bathing, preventing the tourniquet from becoming wet and losing its effectiveness. This technique maintains the pressure needed for venipuncture.
A, providing a bed bath instead of a shower, is unrelated to the use of a tourniquet. B, using sterile technique for dressing changes, is important for wound care but not relevant to tourniquet use. C, disconnecting intravenous fluid tubing before a bath, is essential for preventing contamination but not directly related to tourniquet management.
A nurse teaches a client who is prescribed a central vascular access device. Which statement should the nurse include in this clients teaching?
- A. You will need to wear a sling on your arm while the device is in place
- B. There is no risk of infection because sterile technique will be used during insertion.
- C. . Ask all providers to vigorously clean the connections prior to accessing the device.
- D. You will not be able to take a bath with this vascular access device.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Choice C is correct because it emphasizes the importance of cleaning connections before accessing the device to prevent infection.
2. Sterile technique during insertion cannot guarantee no risk of infection (Choice B).
3. Wearing a sling is unnecessary for a central vascular access device (Choice A).
4. The statement about not being able to take a bath is not accurate and is not a common restriction (Choice D).
. 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 is assessing a client who has acute pancreatitis and is at risk for an acid-base imbalance. For which manifestation of this acid-base imbalance should the nurse assess?
- A. Agitation
- B. Kussmaul respirations
- C. Seizures
- D. Positive Chvosteks sign
Correct Answer: B
Rationale: The correct answer is B: Kussmaul respirations. In acute pancreatitis, metabolic acidosis can occur due to the release of pancreatic enzymes. Kussmaul respirations are deep, rapid breaths that help to blow off excess carbon dioxide in response to acidosis, aiming to correct the pH imbalance. Agitation (A) is a nonspecific symptom and not specific to acid-base imbalances. Seizures (C) are more commonly associated with electrolyte imbalances such as hyponatremia or hypocalcemia. Positive Chvostek's sign (D) is a clinical sign of hypocalcemia, not directly related to acid-base imbalances in acute pancreatitis.