Nokea
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, there is an accumulation of carbon dioxide in the bloodstream due to inadequate ventilation. This leads to increased levels of carbonic acid, causing the blood pH to decrease. The nurse should identify this mechanism as responsible for the acid-base imbalance.
Loss of bicarbonate (B) would lead to metabolic acidosis, not respiratory acidosis. Excessive vomiting (C) would result in metabolic alkalosis. Hyperventilation (D) would actually help correct respiratory acidosis by blowing off excess carbon dioxide.
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A nurse is assessing a client who has skeletal traction for a femoral fracture. The nurse notes that the weights are resting on the floor. Which of the following actions should the nurse take?
- A. Remove one of the weights.
- B. Tie knots in the ropes near the pulleys to shorten them.
- C. Increase the elevation of the affected extremity.
- D. Reapply the weights to ensure proper traction.
Correct Answer: D
Rationale: The correct answer is D: Reapply the weights to ensure proper traction. When the weights are resting on the floor, it means that there is no longer effective traction on the affected limb. To maintain proper skeletal traction, the weights should be suspended freely in the air. By reapplying the weights and ensuring they are hanging freely, the nurse can restore the necessary traction force to immobilize the fractured bone and facilitate healing. Removing a weight (choice A) may compromise the traction. Tying knots in the ropes (choice B) may alter the mechanics of the traction system. Increasing the elevation of the extremity (choice C) does not address the issue of the weights resting on the floor.
A nurse is assessing a client who is 4 hr postoperative following arterial revascularization of the left femoral artery. Which of the following findings should the nurse report to the provider immediately?
- A. Temperature of 37.9° C (100.2° F)
- B. Pallor in the affected extremity
- C. Bruising around the incisional site
- D. Urine output 150 mL over 4 hr
Correct Answer: B
Rationale: The correct answer is B: Pallor in the affected extremity. Pallor in the affected extremity post arterial revascularization could indicate compromised blood flow, potentially leading to ischemia or thrombosis. This is a critical finding that requires immediate intervention to prevent further complications such as tissue necrosis or limb loss.
Incorrect choices:
A: Temperature elevation may indicate infection, but it is not an immediate concern postoperatively.
C: Bruising around the incisional site is common after surgery and may not require immediate intervention unless there are signs of excessive bleeding.
D: Urine output of 150 mL over 4 hr is within normal limits and not a priority concern in this context.
Which findings indicate the client's condition has improved? (Select all that apply)
- A. Pain level
- B. Respiratory rate
- C. Heart rate
- D. Blood pressure
- E. Echocardiogram results
- F. Urinary Output
- G. Oxygenation Saturation
Correct Answer: A, B
Rationale: The correct answers are A and B. Pain level indicates the client's subjective improvement, while respiratory rate reflects their physiological status. Pain reduction suggests improved comfort and possibly better overall health, while a decrease in respiratory rate may indicate improved oxygenation and reduced stress. Choices C, D, E, F, and G are not directly linked to the client's overall condition improvement as they can vary for several reasons, independent of the client's actual health status.
A nurse is assessing a client who has a history of type 2 diabetes mellitus. The nurse should identify which of the following findings as an indication of a microvascular complication?
- A. Peripheral neuropathy
- B. Hypertension
- C. Retinopathy
- D. Stroke
Correct Answer: C
Rationale: The correct answer is C: Retinopathy. In type 2 diabetes, prolonged high blood sugar levels can damage small blood vessels in the retina, leading to retinopathy, a microvascular complication affecting the eyes. This can result in vision problems or even blindness. Peripheral neuropathy (A) is a macrovascular complication affecting the nerves, not the microvasculature. Hypertension (B) is a common comorbidity but not a direct microvascular complication. Stroke (D) is a macrovascular complication involving large blood vessels in the brain, not microvasculature. Thus, the nurse should identify retinopathy (C) as the correct indication of a microvascular complication in a client with type 2 diabetes mellitus.
A nurse is teaching a client who has Graves' disease about recognizing the manifestations of thyroid storm. Which of the following findings should the nurse include in the teaching?
- A. Lethargy
- B. Hypotension
- C. Decreased heart rate
- D. Increased temperature
Correct Answer: D
Rationale: The correct answer is D: Increased temperature. In thyroid storm, there is excessive thyroid hormone production leading to hyperthyroidism symptoms, including increased body temperature. Lethargy (A) is more indicative of hypothyroidism. Hypotension (B) is not a typical finding in thyroid storm; instead, hypertension is more common. Decreased heart rate (C) is also not a common manifestation as tachycardia is typically present in thyroid storm. Therefore, option D is the most appropriate manifestation to recognize in thyroid storm.