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Blood for arterial blood gas determinations is drawn from a client with pneumonia, and testing reveals a pH of 7.45, PCO2 of 30 mm Hg, and HCO3 of 19 mEq/L. The nurse interprets these results as indicative of:
- A. Compensated metabolic acidosis
- B. Compensated respiratory alkalosis
- C. Uncompensated metabolic alkalosis
- D. Uncompensated respiratory acidosis
Correct Answer: B
Rationale: The correct answer is 'Compensated respiratory alkalosis.' In this case, the client's pH is within the normal range (7.35-7.45), indicating compensation. The low PCO2 (30 mm Hg) suggests respiratory alkalosis, while the low HCO3 (19 mEq/L) is also consistent with a compensatory response. Therefore, the client has a primary respiratory alkalosis that is being compensated for by metabolic acidosis. Choices A, C, and D are incorrect because they do not fit the pattern of the given blood gas values, which indicate respiratory alkalosis with metabolic compensation.
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After undergoing a renal biopsy, a client reports pain radiating to the front of the abdomen from the biopsy site. What finding should the nurse assess the client for?
- A. Bleeding
- B. Renal colic
- C. Infection at the site
- D. Increased temperature
Correct Answer: A
Rationale: The correct answer is A: Bleeding. Pain radiating to the front of the abdomen from the renal biopsy site suggests bleeding, which should be promptly assessed and managed. Bleeding can lead to serious complications if not addressed timely. Renal colic (choice B) is associated with kidney stones and typically presents with severe flank pain. Infection at the site (choice C) would more likely present with localized signs such as redness, swelling, warmth, and tenderness. Increased temperature (choice D) alone is not specific to the issue described and may be indicative of various conditions.
The nurse is teaching a patient who will be discharged home from the hospital to take amoxicillin (Amoxil) twice daily for 10 days. Which statement by the nurse is correct?
- A. Discontinue the antibiotic when your temperature returns to normal and your symptoms have improved.
- B. If diarrhea occurs, stop taking the drug immediately and contact your provider.
- C. Stop taking the drug and notify your provider if you develop a rash while taking this drug.
- D. You may save any unused antibiotic to use if your symptoms recur.
Correct Answer: C
Rationale: Patients who develop signs of allergy, such as rash, should notify their provider before continuing medication therapy. Patients should be counseled to continue taking their antibiotics until completion of the prescribed regimen even when they feel well. Diarrhea is an adverse effect but does not warrant cessation of the drug. Before deciding to stop taking a medication due to a side effect, encourage the patient to contact the provider first. Patients should discard any unused antibiotic.
The healthcare provider is caring for a 7-year-old patient who will receive oral antibiotics. Which antibiotic order will the healthcare provider question for this patient?
- A. Azithromycin (Zithromax)
- B. Clarithromycin (Biaxin)
- C. Clindamycin (Cleocin)
- D. Tetracycline (Sumycin)
Correct Answer: D
Rationale: The correct answer is D, Tetracycline (Sumycin). Tetracyclines should not be given to children younger than 8 years of age because they irreversibly discolor the permanent teeth. Azithromycin, Clarithromycin, and Clindamycin are antibiotics that are generally safe for use in children and do not have the same tooth discoloration side effect as Tetracycline. Therefore, these antibiotics would be more appropriate choices for a 7-year-old patient.
A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take?
- A. Document findings and continue to monitor the client.
- B. Contact the provider and recommend a 24-hour urine test.
- C. Review the client's recent dietary selections.
- D. Perform a capillary artery glucose assessment.
Correct Answer: D
Rationale: Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL, which means that a person whose blood glucose is less than 220 mg/dL will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a capillary artery glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor is not appropriate. Requesting a 24-hour urine test or reviewing the client's dietary selections will not assist the nurse to make a clinical decision related to this abnormality.
A client has just regained bowel sounds after undergoing surgery. The physician has prescribed a clear liquid diet for the client. Which of the following items should the nurse ensure is available in the client's room before allowing the client to drink?
- A. Straw
- B. Napkin
- C. Oxygen saturation monitor
- D. Suction equipment
Correct Answer: D
Rationale: After surgery, when a client has just regained bowel sounds and is prescribed a clear liquid diet, the nurse needs to consider the possibility of impaired swallow reflexes due to anesthesia effects, leading to an increased risk of aspiration. Despite checking the gag and swallow reflexes before offering fluids, having suction equipment readily available in the client's room is essential to manage any potential aspiration risk. Therefore, the correct answer is suction equipment (choice D). Choices A, B, and C are incorrect because while a straw, napkin, and oxygen saturation monitor may be useful in other situations, they are not directly related to managing the risk of aspiration associated with offering fluids to a client post-surgery.