Nokea
The client is admitted with chronic obstructive pulmonary disease. Blood gases reveal pH 7.36, CO2 45, O2 84, HCO3 28. The nurse would assess the client to be in:
- A. Uncompensated acidosis
- B. Compensated alkalosis
- C. Compensated respiratory acidosis
- D. Uncompensated metabolic acidosis
Correct Answer: C
Rationale: The client is experiencing compensated respiratory acidosis. The pH is within the normal range but is lower than 7.40, indicating acidity. The elevated CO2 level and low O2 level suggest respiratory involvement. The slightly elevated HCO3 level indicates a compensatory mechanism. In respiratory acidosis, the pH will be inversely related to the CO2 and bicarb levels, with elevated CO2 and HCO3 levels contributing to acidosis. Choices A, B, and D are incorrect because they do not align with the presented blood gas values and the compensatory response observed in this case.
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The client with cirrhosis of the liver is receiving Lactulose. The nurse is aware that the rationale for the order for Lactulose is:
- A. To lower the blood glucose level
- B. To lower the uric acid level
- C. To lower the ammonia level
- D. To lower the creatinine level
Correct Answer: C
Rationale: Lactulose is administered to the client with cirrhosis to lower ammonia levels, as it works by acidifying the colon, trapping ammonia for elimination in the stool. Choices A, B, and D are incorrect because Lactulose does not have an effect on blood glucose, uric acid, or creatinine levels. Therefore, the correct answer is to lower the ammonia level.
A client with glomerulonephritis is placed on a low-sodium diet. Which of the following snacks is suitable for the client with sodium restriction?
- A. Peanut butter cookies
- B. Grilled cheese sandwich
- C. Cottage cheese and fruit
- D. Fresh peach
Correct Answer: D
Rationale: The correct answer is a fresh peach. It is the most suitable snack for a client with sodium restriction as it is naturally low in sodium. Peanut butter cookies (choice A), grilled cheese sandwich (choice B), and cottage cheese and fruit (choice C) contain higher amounts of sodium, making them unsuitable choices for someone on a low-sodium diet. Fresh fruits like peaches are excellent options for individuals on a low-sodium diet as they are not only low in sodium but also provide essential nutrients and hydration.
Which of the following describes the stages of domestic violence in an intimate relationship?
- A. happiness, crisis, angry outburst, intervention
- B. honeymoon period, escalation of stress, outburst, reconciliation
- C. acting out and making up
- D. peace and calm, angry outburst, peace and calm, denial
Correct Answer: B
Rationale: The correct answer is B: 'honeymoon period, escalation of stress, outburst, reconciliation.' A pattern of behavior known as the cycle of abuse involves these stages. It starts with a honeymoon phase, followed by a buildup of stress, an outburst which may involve violence, and then reconciliation. This cycle is commonly observed in domestic violence situations. Choices A, C, and D do not accurately represent the stages of domestic violence in intimate relationships. Choice A mixes positive and negative elements, while choice C simplifies the complex dynamics of domestic violence. Choice D repeats 'peace and calm' inappropriately and includes 'denial,' which is not typically a stage in the cycle of abuse.
The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?
- A. A gravida IV para 3 that is Rh negative with an Rh-positive baby
- B. A gravida I para 1 that is Rh negative with an Rh-positive baby
- C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
- D. A gravida IV para 2 that is Rh negative with an Rh-negative baby
Correct Answer: D
Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.
The nurse is caring for a client with epilepsy who is being treated with carbamazepine (Tegretol). Which laboratory value might indicate a serious side effect of this drug?
- A. Uric acid of 5 mg/dL
- B. Hematocrit of 33%
- C. WBC 2,000 per cubic millimeter
- D. Platelets 150,000 per cubic millimeter
Correct Answer: C
Rationale: Carbamazepine (Tegretol) can suppress the bone marrow, leading to a decrease in the white blood cell count. A laboratory value of WBC 2,000 per cubic millimeter indicates a serious side effect of the drug. Choices A and D are within normal limits, while choice B is at the lower limit of normal. Therefore, choices A, B, and D are incorrect.