Nokea
A nurse obtained a client's pulse and found the rate to be above normal. The nurse documents these findings as:
- A. Tachypnea
- B. Hyperpyrexia
- C. Arrhythmia
- D. Tachycardia
Correct Answer: D
Rationale: Tachycardia is an elevated heart rate; tachypnea is rapid breathing, hyperpyrexia is high fever, and arrhythmia is irregular rhythm.
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The nurse is caring for a client receiving oxygen therapy via a simple face mask. Which nursing intervention is important to prevent skin breakdown?
- A. Changing the position of the mask every 2 hours
- B. Applying a protective barrier cream to the client's face
- C. Padding the pressure points on the client's face with soft material
- D. Encouraging the client to remove the mask intermittently for facial skin care
Correct Answer: C
Rationale: Padding pressure points with soft material (C) prevents skin breakdown from a simple face mask by reducing friction and pressure on the face. Repositioning q2h (A) helps but isn't enough alone. Barrier cream (B) is for moisture, not pressure. Intermittent removal (D) disrupts therapy. Padding, per skin integrity standards, is proactive.
The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis?
- A. pH of 7.35, Pco2 of $50 \mathrm{~mm} \mathrm{Hg}, \mathrm{HCO} 3- of $32 \mathrm{mEq} / \mathrm{L}$
- B. pH of 7.45, Pco2 of $35 \mathrm{~mm} \mathrm{Hg}, \mathrm{HCO} 3- of $22 \mathrm{mEq} / \mathrm{L}$
- C. pH of 7.38, Pco2 of $45 \mathrm{~mm} \mathrm{Hg}, \mathrm{HCO} 3- of $32 \mathrm{mEq} / \mathrm{L}$
- D. pH of 7.48, Pco2 of $40 \mathrm{~mm} \mathrm{Hg}, \mathrm{HCO} 3- of $36 \mathrm{mEq} / \mathrm{L}$
Correct Answer: D
Rationale: Metabolic alkalosis features high pH (>7.45) and elevated HCO3- (>26 mEq/L) with normal Pco2 (35-45 mm Hg). Option D (pH 7.48, Pco2 40, HCO3- 36) fits this, indicating excess base. A is respiratory acidosis. B is normal. C is compensated. D is correct. Rationale: High HCO3- from vomiting or diuretics causes alkalosis, uncompensated here, per ABG interpretation principles.
An adult client is on extreme pain. He is moaning and grimacing. What is the best way to assess the client's pain?
- A. Perform physical assessment
- B. Have the client rate his pain on the smiley pain rating scale
- C. Active listening on what the patient says
- D. Observe the client's behavior
Correct Answer: B
Rationale: Rating pain on a smiley scale (B) is best for an adult in extreme pain; it quantifies subjective experience, per pain assessment tools. Physical assessment (A) is secondary, listening (C) misses rating, observing (D) lacks precision. B captures intensity, making it correct.
A client with chronic obstructive pulmonary disease (COPD) presents with severe dyspnea and hypoxemia. What is the appropriate indication for initiating oxygen therapy in this client?
- A. Maintaining oxygen saturation above 95%
- B. Correcting underlying lung pathology
- C. Relieving shortness of breath
- D. Preventing complications of hypoxia
Correct Answer: D
Rationale: Preventing complications of hypoxia (D) is the primary indication for oxygen therapy in COPD with severe dyspnea and hypoxemia, averting tissue damage and organ failure (target SpO2 88-92%). Saturation above 95% (A) risks CO2 retention in COPD. Correcting pathology (B) requires other treatments. Relieving dyspnea (C) is a benefit, not the goal. Hypoxia prevention aligns with GOLD guidelines, prioritizing survival and function over symptom relief alone.
The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:
- A. Instructing the patient about this diagnostic test
- B. Writing the order for this test
- C. Giving the patient breakfast
- D. All of the above
Correct Answer: C
Rationale: The nurse ensures the patient eats, while the physician handles test orders and instructions.