Nokea
A nurse is caring for a client who has acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply).
- A. Hypoxemia
- B. Confusion
- C. Dyspnea
- D. Bradycardia
- E. Hypocarbia
Correct Answer: A,B,C,E
Rationale: These are common manifestations of ARF reflecting impaired gas exchange and cerebral effects of abnormal blood gases.
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A client is admitted to the emergency room with renal calculi. Upon assessment, which of the following findings should the nurse expect?
- A. Bradycardia
- B. Bradypnea
- C. Severe pain
- D. Nocturia
Correct Answer: C
Rationale: Severe pain (renal colic) is the most common symptom of renal calculi, caused by the stone moving and blocking the ureter.
A nurse is assessing a client who sustained a basal skull fracture and notes a thin stream of clear drainage coming from the client's right nostril. Which of the following actions should the nurse take first?
- A. Test the drainage for the halo sign.
- B. Ask the client to blow his nose.
- C. Notify the physician.
- D. Suction the nostril.
Correct Answer: A
Rationale: Testing for the halo sign (glucose in drainage) helps identify CSF leakage which requires immediate intervention.
A nurse is reviewing a client's laboratory report of arterial blood gas (ABG) findings: pH 7.28, HCO3 18, and PaCO2 36. Which of the following conditions should the nurse anticipate when interpreting these findings?
- A. Metabolic alkalosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Respiratory acidosis
Correct Answer: C
Rationale: Low pH with low HCO3 indicates metabolic acidosis with appropriate respiratory compensation.
A nurse is caring for a client who had a stroke and has dysphagia. For which of the following complications should the nurse monitor the client?
- A. Aspiration
- B. Gastroesophageal reflux disease
- C. Peptic ulcer disease
- D. Dumping syndrome
Correct Answer: A
Rationale: Aspiration is the primary concern with dysphagia due to impaired swallowing reflexes.
A client arrives at the emergency room with symptoms of peptic ulcer disease. Which of these symptoms should the nurse identify as the priority?
- A. Hematemesis
- B. Abdominal bloating
- C. Epigastric discomfort
- D. Dyspepsia
Correct Answer: A
Rationale: Hematemesis indicates active bleeding and is the most urgent concern.