Nokea
A nurse is caring for a client whose arterial blood gases include a pH of 7.30, an HCO3- of 18 mEq/L and a PaCO2 of 28 mm Hg. The nurse should suspect that the client has developed which of the following acid-base imbalances?
- A. Metabolic acidosis
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: The correct answer is A: Metabolic acidosis. The pH is low (acidosis) and the HCO3- is also low, indicating a primary metabolic acidosis. The low PaCO2 (respiratory alkalosis compensation) further supports metabolic acidosis. Other choices are incorrect because B: Respiratory acidosis would have a high PaCO2, C: Metabolic alkalosis would have a high HCO3-, and D: Respiratory alkalosis would have a low PaCO2 with a high pH.
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A nurse is caring for a client who is requesting information about how to enhance her immune system. The nurse should identify that which of the following complementary and alternative healing modalities uses the essential oils of plants to provide psychological and physiological benefit.
- A. Aromatherapy
- B. Biofeedback
- C. Guided imagery
- D. Yoga
Correct Answer: A
Rationale: Aromatherapy uses essential oils from plants to promote relaxation, improve mood, and support immune function.
A nurse is reinforcing teaching with a client who has fibrocystic breast changes about dietary changes that can help minimize symptoms. Which of the following dietary elements should the nurse instruct the client to limit?
- A. Fat
- B. Water
- C. Calcium
- D. Vitamin E
Correct Answer: A
Rationale: A diet low in fat has been shown to help reduce fibrocystic breast pain and discomfort.
A young adult tells the nurse in the provider's office that he is concerned about the amount of sleep he is getting. The nurse should explain that which of the following durations is the average recommendation for sleep for a young adult?
- A. 8 hr
- B. 11 hr
- C. 12 hr
- D. 14 hr
Correct Answer: A
Rationale: The correct answer is A: 8 hr. The average recommendation for sleep for a young adult is typically around 7-9 hours per night. This amount allows for adequate rest and helps maintain overall health and well-being. Choice B (11 hr), C (12 hr), and D (14 hr) are excessive amounts of sleep that are not necessary for young adults and could potentially lead to negative effects such as grogginess or difficulty waking up. Therefore, option A is the most appropriate and balanced choice for a young adult's sleep duration.
A nurse is collecting data from an adolescent client. Which of the following behaviors should the nurse expect an adolescent who has achieved successful resolution of the developmental tasks of identity vs. role confusion to exhibit?
- A. Expresses her opinions
- B. Uses time effectively
- C. Starts and completes a task
- D. Establishes a close relationship with another person
Correct Answer: A
Rationale: The correct answer is A: Expresses her opinions. Adolescents who have successfully resolved the developmental task of identity vs. role confusion are more likely to express their opinions confidently and assertively as they have a clear sense of self and have developed their own identity. This behavior reflects their ability to articulate their thoughts and beliefs, showing autonomy and independence.
Summary of other choices:
B: Using time effectively is a good skill but not directly related to resolving identity vs. role confusion.
C: Starting and completing tasks is important, but not indicative of resolving identity issues.
D: Establishing close relationships is important, but it is not the primary behavior associated with resolving identity vs. role confusion.
A nurse is caring for a client who is 2 days postoperative following a right hemicolectomy. When the nurse enters the client's room, he states that, following a bout of coughing, 'something popped in my belly.' The nurse lifts the sheets and sees that the client's gown is bloody. After sending a coworker to get the charge nurse and call the surgeon, which of the following actions should the nurse take next?
- A. Position the client supine with his hips and knees bent.
- B. Prepare to administer an IV infusion of 0.9% sodium chloride.
- C. Cover the wound with moist sterile gauze.
- D. Measure the client's vital signs.
Correct Answer: C
Rationale: Evisceration requires immediate covering of the wound with a sterile, moist dressing to prevent infection and tissue damage.