Nokea
The client has been vomiting for several days. Which blood gas values is he likely to have?
- A. pH=7.32; CO2=60; HCO3=30
- B. pH=7.32; CO2=33; HCO3=18
- C. pH=7.54; CO2=28; HCO3=22
- D. pH=7.54; CO2=32; HCO3=34
Correct Answer: C
Rationale: Prolonged vomiting causes metabolic alkalosis (high pH, low CO2) due to loss of stomach acid, matching pH=7.54, CO2=28, HCO3=22.
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The nurse is auscultating a client's breath sounds and identifies rhonchi. The nurse should recognize that rhonchi is consistent with
- A. croup
- B. pleurisy
- C. bronchitis
- D. pneumothorax
Correct Answer: C
Rationale: Rhonchi are low-pitched, rattling sounds caused by mucus or fluid in larger airways, commonly associated with bronchitis.
The nurse has assigned a nursing assistant to give the client a bath. Which observation reported by the nursing assistant requires immediate attention by the nurse?
- A. A red area on the back that disappears after it is massaged
- B. A red area on the hip that does not go away after the area is massaged
- C. The client's insistence on doing most of the bath
- D. The indwelling urethral catheter is draining clear, amber urine.
Correct Answer: B
Rationale: A non-blanching red area on the hip suggests a pressure injury, requiring immediate nursing intervention to prevent progression.
The family of a young man who has been declared brain dead following an accident tells the nurse that the doctors said their son would be a good organ donor. They ask the nurse if donating his organs would mean that they could not have a regular funeral. Which response by the nurse is most accurate?
- A. Donating organs does deface the body, so a closed casket is necessary.
- B. Ask the physician which organs would be donated.
- C. Organ donation involves a surgical incision but should not interfere with any type of funeral.
- D. Donating organs is a wonderful service to humanity.
Correct Answer: C
Rationale: Organ donation involves surgical incisions but allows for open-casket funerals with proper preparation, addressing the family's concern accurately.
What is the major developmental task that the mother must accomplish during the first trimester of pregnancy?
- A. Acceptance of the pregnancy
- B. Acceptance of the termination of the pregnancy
- C. Acceptance of the fetus as a separate and unique being
- D. Satisfactory resolution of fears related to giving birth
Correct Answer: A
Rationale: Acceptance of the pregnancy. During the first trimester the maternal focus is directed toward acceptance of the pregnancy and adjustment to the minor discomforts.
The nurse is caring for assigned clients. The nurse should first check the client
- A. with hypothyroidism who is reporting constipation, weakness, and peripheral edema
- B. with chronic pancreatitis who is reporting upper abdominal pain and voluminous, foul-smelling, fatty stools
- C. who has bacterial pneumonia, is receiving IV antibiotic therapy, and is reporting a cough productive of blood-tinged sputum
- D. who has an external fixation device, a temperature of 101.8°F (38.8°C), and is reporting redness and pain around the pin sites
Correct Answer: D
Rationale: Fever, redness, and pain around pin sites suggest a possible infection at the external fixation site, which is a priority due to the risk of osteomyelitis or systemic infection.