Nokea
A nurse is collecting data from a client whose arterial blood gas values reveal a pH of 7.24, PaCO₂ of 53, and an HCO₃ of 24. The nurse should prepare to treat the client for which of the following acid-base imbalances?
- A. Metabolic acidosis.
- B. Metabolic alkalosis.
- C. Respiratory acidosis.
- D. Respiratory alkalosis.
Correct Answer: C
Rationale: Low pH (7.24) and high PaCO₂ (53) indicate respiratory acidosis due to CO₂ accumulation from inadequate ventilation.
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A nurse is administering morning medications and realizes that nifedipine was administered to the wrong client. Which of the following is the priority nursing action?
- A. Notify the charge nurse.
- B. Check the client's vital signs.
- C. Fill out an occurrence report according to institutional policy.
- D. Document an objective description of what has happened in the client's chart.
Correct Answer: B
Rationale: Checking the client's vital signs is the priority to assess for adverse effects, such as hypotension, ensuring immediate safety.
A nurse is caring for a client who has a prescription for clopidogrel. Which of the following actions should the nurse plan to take?
- A. Administer the medication with each meal.
- B. Initiate contact precautions.
- C. Have suction equipment at the bedside.
- D. Monitor the client for black, tarry stools.
Correct Answer: D
Rationale: Monitoring for black, tarry stools is crucial as clopidogrel increases bleeding risk, indicating potential gastrointestinal bleeding.
A nurse is preparing to administer levothyroxine 100 mcg PO to a client who has hypothyroidism. Available is levothyroxine 50 mcg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies.(Do not use a trailing zero.)
Correct Answer: 1 tablet
Rationale: 100 mcg ÷ 50 mcg/tablet = 2 tablets. The nurse should administer 2 tablets.
A nurse is collecting data from a client who has peripheral arterial disease (PAD). Which of the following findings should the nurse expect?
- A. Warm extremities.
- B. Darkened skin color near extremities.
- C. Intermittent claudication.
- D. Edema.
Correct Answer: C
Rationale: Intermittent claudication, pain or cramping in the legs during exercise that subsides with rest, is a hallmark symptom of PAD due to reduced blood flow.
A nurse is reinforcing teaching with a client who has recurrent urinary tract infections (UTIs) about prevention measures. Which of the following client statements indicates the need for further teaching?
- A. I should avoid taking bubble baths.
- B. I will need to empty my bladder after having sexual intercourse.
- C. I will need to wipe my perineal area from back to front after urination.
- D. I need to drink at least 8 full glasses of liquid each day.
Correct Answer: C
Rationale: Wiping from back to front can transfer bacteria to the urethra, increasing UTI risk, indicating a need for further teaching on proper hygiene.