Nokea
An adult has the following blood gasses: pH=7.52, pCO2=50, HCO3=35, and pO2=90. What is most likely to be in the client's history of presenting signs and symptoms?
- A. Persistent diarrhea
- B. Frequent vomiting
- C. Anxiety attack
- D. Emphysema
Correct Answer: B
Rationale: High pH and HCO3 indicate metabolic alkalosis, commonly caused by frequent vomiting, losing gastric acid.
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The nurse is caring for a client with a history of heart failure who is receiving digoxin (Lanoxin) 0.25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have nausea and no appetite.
- C. I have a headache sometimes.
- D. I take my medication with food.
Correct Answer: B
Rationale: Nausea and loss of appetite are signs of digoxin toxicity, a serious complication requiring immediate evaluation, especially in heart failure. Options A, C, and D are less concerning: fatigue and headaches are nonspecific, and taking digoxin with food is acceptable.
The nurse is caring for a client with a history of atrial fibrillation.
- A. Which medication should the nurse expect to administer to a client with atrial fibrillation to prevent thromboembolism?
- B. Aspirin.
- C. Heparin.
- D. Warfarin (Coumadin).
- E. Clopidogrel (Plavix).
Correct Answer: C
Rationale: Warfarin is the standard anticoagulant for preventing thromboembolism in atrial fibrillation, reducing stroke risk. Aspirin and clopidogrel are antiplatelets, and heparin is used short-term or in acute settings.
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
- A. Lung sounds
- B. Urine output
- C. Level of alertness
- D. Appetite
Correct Answer: C
Rationale: Level of alertness. Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.
A child who received meperidine (Demerol) IM one hour ago.
The nurse knows that which of the following is the BEST assessment indicating relief from abdominal pain for a child who received meperidine (Demerol) IM one hour ago?
- A. The child states that his pain has gone away.
- B. The child's heart rate has changed from 80 to 95.
- C. The child sleeps except when receiving nursing care.
- D. Results from the incentive spirometer have improved.
Correct Answer: D
Rationale: Strategy: Think about what the words mean. (1) contains correct information, but is not a priority; child could deny pain out of fear of getting another injection (2) indicates discomfort, anxiety (3) indicates a need to decrease the amount of medication (4) correct-when pain is decreased, child will be better able to breathe deeply and improve the outcome of use of the incentive spirometer
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should
- A. place a call to the client's provider for instructions
- B. send him to the emergency room for evaluation
- C. reassure the client's partner that the symptoms are transient
- D. instruct the client's partner to call the provider if his symptoms become worse
Correct Answer: B
Rationale: This client requires immediate evaluation. A delay in treatment could result in further deterioration of his condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest.