Nokea
Select the arterial blood gas that you would report to the client's physician because it is not within normal parameters and it is also a significant change for the client.
- A. PaO2: 65 mm Hg
- B. PaCO2: 40 mm Hg
- C. Arterial blood pH: 7.39
- D. SaO2: 96%
Correct Answer: A
Rationale: PaO2 of 65 mm Hg is below the normal range (75-100 mm Hg), indicating hypoxemia, which requires reporting.
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A client is receiving a tube feeding and has developed diarrhea, cramps, and abdominal distention. Which of the following interventions would be most appropriate? Select all that apply.
- A. Change the feeding apparatus every 24 hours.
- B. Use a higher volume of formula because the normal loss of the blood pressure.
- C. Slow the administration rate.
- D. Use a diluted formula, gradually increasing the volume and concentration.
- E. Anticipate changing to a lactose-free formula.
Correct Answer: A, C, D, E
Rationale: Changing the apparatus, slowing the rate, using diluted formula, and switching to lactose-free formula help manage diarrhea and distention.
You are caring for a multiple trauma client who has just arrived at the emergency room with a number of other external disaster victims. This client has multiple blast injuries and hypovolemic shock; it is anticipated that this unstable critically injured and unconscious client will have long term intravenous therapy, blood products and possibly hyperalimentation as well. Which type of venous access would you most likely anticipate for this client?
- A. A percutaneous, non tunneled subclavian catheter
- B. A peripheral intravenous catheter that is 20 gauge
- C. A multi lumen implanted tunneled and cuffed central venous catheter
- D. A peripherally inserted central venous catheter
Correct Answer: C
Rationale: A multi-lumen implanted tunneled and cuffed central venous catheter is most appropriate for long-term IV therapy, blood products, and hyperalimentation due to its durability and reduced infection risk.
The nurse should turn the client on bed rest every 2 hours to prevent the development of pressure ulcers. In addition, the nurse should:
- A. Have the client walk at least twice a day
- B. Insert an indwelling urinary catheter
- C. Monitor serum albumin
- D. Monitor the white blood cell count
Correct Answer: C
Rationale: Monitoring serum albumin assesses nutritional status, which is critical for skin integrity and preventing pressure ulcers. Walking is contraindicated for bed rest, catheters increase infection risk, and white blood cell count is less relevant.
You are working in a community pediatric health clinic. Which developmental task should you apply into your practice?
- A. You should apply the principles of initiative when caring for preschool children.
- B. You should apply the principles of sensorimotor thought when caring for preschool children.
- C. You should apply the principles of intimacy when caring for the adolescent.
- D. You should apply the principles of concrete operations when caring for the adolescent.
Correct Answer: A
Rationale: According to Erikson's developmental stages, preschool children (ages 3-5) are in the stage of Initiative vs. Guilt, where they develop a sense of purpose through exploration and play. This is the appropriate developmental task to apply in a pediatric clinic for this age group.
The mother of a 2-year-old who has been bitten by the family dog asks the nurse what to do about the bite. What should the nurse tell the mother?
- A. You need to take the child to the local urgent recommended by the 1980'
- B. Wash the bite area with lots of running water, and then check the injury.'
- C. Determine when the child's latest tetanus vaccine was administered.'
- D. Make an appointment to see the child's physician now to start rabies shots.'
Correct Answer: B
Rationale: Washing the bite area with running water helps clean the wound and reduce infection risk. Tetanus status and rabies risk can be assessed afterward, but immediate cleaning is the priority.