Nokea
The client's blood gas values are: pH=7.35; CO2=60; HCO3=34; and pO2=60. The nurse correctly interprets these to indicate that the client is in which state?
- A. Compensated respiratory acidosis
- B. Partly compensated metabolic alkalosis
- C. Metabolic alkalosis
- D. Metabolic acidosis
Correct Answer: A
Rationale: Normal pH with elevated CO2 and HCO3 indicates compensated respiratory acidosis, where kidneys retain bicarbonate to balance chronic CO2 retention.
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For a client with Graves' disease, which nursing intervention promotes comfort?
- A. Restricting intake of oral fluids
- B. Placing extra blankets on the client's bed
- C. Limiting intake of high-carbohydrate foods
- D. Maintaining room temperature in the low-normal range
Correct Answer: D
Rationale: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range. To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort. To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
Homonymous hemianopsia:
Homonymous hemianopsia:
- A. Half of the visual field of the affected eye is lost.
- B. The pupil in the affected eye is always dilated.
- C. Lost of vision on the affected eye.
- D. The pupil in the affected eye is not constricting.
Correct Answer: A
Rationale: Homonymous hemianopsia involves loss of half the visual field in both eyes, same side.
A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse?
- A. foul smelling urine
- B. burning on urination
- C. elevated temperature
- D. nausea and anorexia
Correct Answer: C
Rationale: Elevated temperature after 72 hours on an antibiotic indicates the antibiotic has not been effective in eradicating the offending organism. The provider should be informed immediately so that an appropriate medication can be prescribed, and complications such as pyelonephritis are prevented.
A patient with borderline personality disorder is exhibiting self-harming behaviors. Which of the following interventions is most appropriate?
- A. Ignore the self-harming behaviors
- B. Provide immediate medical care for injuries
- C. Punish the patient for self-harming
- D. Encourage the patient to discuss their feelings
Correct Answer: B
Rationale: Providing immediate medical care for injuries ensures safety and addresses physical harm, the priority in self-harming behaviors. Ignoring, punishing, or only discussing feelings delays critical intervention.
A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief system, the nurse would explain that illness is attributed to the
- A. Yang, the positive force that represents light, warmth, and fullness
- B. Yin, the negative force that represents darkness, cold, and emptiness
- C. Use of improper hot foods, herbs and plants
- D. A failure to keep life in balance with nature and others
Correct Answer: B
Rationale: Yin, the negative force that represents darkness, cold, and emptiness. Excessive Yin is believed to cause illness in Chinese folk medicine.