Nokea
A nurse is reviewing the laboratory results of a client who is postoperative and has a respiratory rate of 7/min. The arterial blood gas (ABG) values include: pH 7.22, PaCO₂ 68 mm Hg, Base excess -2, PaO₂ 78 mm Hg, Oxygen saturation 80%, Bicarbonate 28 mEq/L. Which of the following interpretations of the ABG values should the nurse make?
- A. Respiratory alkalosis.
- B. Respiratory acidosis.
- C. Metabolic acidosis.
- D. Metabolic alkalosis.
Correct Answer: B
Rationale: Low pH (7.22) and high PaCO₂ (68 mm Hg) indicate respiratory acidosis, caused by CO₂ accumulation due to inadequate ventilation.
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A nurse is preparing to administer ondansetron 4 mg IM stat. The amount available is ondansetron for injection 2 mg/mL. How many mL 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: 2 mL
Rationale: 4 mg ÷ 2 mg/mL = 2 mL. The nurse should administer 2 mL.
Phenazopyridine hydrochloride turns the urine which color?
- A. Purple.
- B. Orange.
- C. Blue.
- D. Green.
Correct Answer: B
Rationale: Phenazopyridine hydrochloride turns the urine orange, a common and harmless side effect due to its dye properties.
A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?
- A. Confusion.
- B. Urinary retention.
- C. Incontinence.
- D. Low back pain.
Correct Answer: A
Rationale: Confusion is a unique symptom of urinary tract infections (UTIs) in older adults, often being the first or only symptom, making it a critical indicator for this age group.
A client who is taking nitrofurantoin for a urinary tract infection voices a concern to the clinic nurse about voiding brown-colored urine. Which of the following is an appropriate response by the nurse?
- A. Drinking more fluid will prevent your urine from becoming brown.
- B. Brown-colored urine is a harmless side effect of the medication.
- C. The provider will change your medication because your infection is not resolving with nitrofurantoin.
- D. An increase of RBC destruction in your blood can result in brown-colored urine.
Correct Answer: B
Rationale: Brown-colored urine is a harmless side effect of nitrofurantoin due to the medication itself, not indicating harm.
A nurse is reinforcing teaching for a client about following a low-purine diet to manage gout. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
- A. I'll drink white wine, not red.
- B. I'll limit the number of fruit servings I eat each day.
- C. I'll choose red meat instead of poultry.
- D. I'll eliminate liver from my diet.
Correct Answer: D
Rationale: Organ meats like liver are high in purines and should be eliminated to manage gout effectively, as purines increase uric acid levels.