Nokea
The client presents to the unit with complaints of shortness of breath. A tentative diagnosis of respiratory acidosis related to pneumonia is made. Which finding would support this diagnosis?
- A. $\mathrm{pH}$ of $7.45, \mathrm{CO}_2$ of $45, \mathrm{HCO}_3$ of 26
- B. $\mathrm{pH}$ of $7.35, \mathrm{CO}_2$ of $46, \mathrm{HCO}_3$ of 27
- C. $\mathrm{pH}$ of $7.34, \mathrm{CO}_2$ of $30, \mathrm{HCO}_3$ of 22
- D. $\mathrm{pH}$ of $7.44, \mathrm{CO}_2$ of $32, \mathrm{HCO}_3$ of 25
Correct Answer: B
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and elevated CO₂ (>45 mmHg) due to impaired gas exchange, as in pneumonia. Option B (pH 7.35, CO₂ 46, HCO₃ 27) is closest to this profile, with slight compensation. Options A, C, and D show normal or alkalotic pH or low CO₂.
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A football player is well paid for his superior athletic ability. Described by his friends as quiet and brooding, on the field he is known for his overly aggressive plays. The client's behavior is an example of:
- A. Displacement
- B. Conversion
- C. Sublimation
- D. Repression
Correct Answer: C
Rationale: Sublimation involves channeling emotions (e.g., aggression) into socially acceptable outlets, like sports. Displacement, conversion, and repression do not fit.
Laboratory reference ranges
BUN
10-20 mg/dL
(3.6-7.1 mmol/L)
An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which of the following data obtained
by the practical nurse is most important to report to the registered nurse before the client receives the next dose?
- A. client reports tinnitus
- B. Blood pressure 104/60 mm Hg
- C. urine output of 400 mL since last dose
Correct Answer: A
Rationale: Tinnitus may indicate ototoxicity, requiring immediate reporting. Low BP and urine output are less urgent without context of medication.
The nurse is caring for a postoperative client who has D5W/0.45% normal saline with 10 mEq potassium chloride infusing through a peripheral IV catheter. What are appropriate reasons for the nurse to change the site? Select all that apply.
- A. Area around the insertion site feels cool to the touch
- B. Client reports mild arm discomfort after the infusion is started
- C. Edema is observed on the dependent side of the involved arm
- D. Intraoperative peripheral IV catheter was placed in the left antecubital region
- E. Serous fluid is leaking from the site despite secure connections
Correct Answer: A,C,E
Rationale: Coolness suggests infiltration or poor circulation. Edema indicates infiltration or phlebitis. Leaking serous fluid suggests dislodgement. Mild discomfort may be normal initially, and antecubital placement is acceptable unless complications arise.
A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action?
- A. Document a description of the injury
- B. Question the parent about where the infant sleeps
- C. Report the injury per facility protocol
- D. Separate the parent from the infant
Correct Answer: C
Rationale: A spiral fracture in a non-mobile infant is inconsistent with rolling off a bed, suggesting abuse. Reporting is the priority to ensure safety. Documentation , questioning , and separation follow.
The nurse is contributing to a staff education program about cancer screening. Which of the following findings should the nurse suggest including as a possible warning sign of cancer?
- A. recent diagnosis of benign prostatic hyperplasia
- B. unintentional weight loss of 15 lb (6.8 kg) over the past 3 months
- C. a doughy, mobile, golf ball-sized lesion under the skin on the thigh
- D. a fever, productive cough, and hoarseness for the past 5 days
Correct Answer: B
Rationale: Unintentional weight loss is a cancer warning sign. BPH is benign, a mobile lesion is likely benign, and cough/fever suggest infection.