Nokea
The nurse is assessing a client with a history of heart failure who is receiving a 500-mL I.V. bolus of 0.9% normal saline. To evaluate the client's response to the treatment, the nurse should especially monitor the client for which of the following?
- A. Hypotension.
- B. Increased urine output.
- C. Crackles in the lungs.
- D. Dry mucous membranes.
Correct Answer: C
Rationale: In heart failure, fluid boluses can lead to pulmonary edema, so monitoring for lung crackles is critical to detect fluid overload.
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Which of the following statements best explains why the nurse should evaluate gastric residual in administering the client's next enteral feeding?
- A. To determine how well nutrients are being absorbed
- B. To determine if the client is receiving enough feeding
- C. To prevent overdistention of the stomach
- D. To prevent mixing undigested formula with partially digested formula
Correct Answer: C
Rationale: Evaluating gastric residual prevents overdistention of the stomach, which can lead to aspiration or discomfort. It does not directly assess nutrient absorption or feeding adequacy.
Which of the following is appropriate for a client with metabolic alkalosis?
- A. Monitor serum potassium levels
- B. Maintain the client on bed rest
- C. Have the client inhale carbon dioxide using a paper bag
- D. Administer sodium bicarbonate as ordered
Correct Answer: A
Rationale: Metabolic alkalosis can cause hypokalemia, so monitoring serum potassium levels is appropriate. Bed rest is not indicated, inhaling CO2 is for respiratory alkalosis, and sodium bicarbonate would worsen alkalosis.
A family has taken home their newborn and later received a call from the pediatrician that the PKU levels for their newborn daughter are abnormally high. Additional testing confirmed the diagnosis of phenylketonuria. The parents refuse to believe the results as no one else in their family has the disease. The nurse explains that the disease:
- A. Is carried on recessive genes contributed by each parent.
- B. Is caused by a recessive gene contributed by either parent.
- C. Is cured by eliminating dietary protein for this child.
- D. Will not impact future childbearing for the family.
Correct Answer: A
Rationale: Phenylketonuria is an autosomal recessive disorder, requiring both parents to contribute a defective gene. It is not caused by a single parent's gene, cannot be cured by diet alone (though managed by low-phenylalanine diet), and may impact future childbearing as parents are carriers.
A client experiencing a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, PCO2 31 mm Hg, PaO2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. Respiratory alkalosis is present when the PCO2 is less than 35, whereas respiratory acidosis is present when the PCO2 is greater than 45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L, whereas metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L. This client's ABGs are consistent with respiratory alkalosis.
The nurse is caring for a client with a burn injury covering 30% of the body. Which fluid should the nurse expect to administer?
- A. Normal saline
- B. Lactated Ringer's
- C. 5% dextrose
- D. Albumin
Correct Answer: B
Rationale: Lactated Ringer's is the preferred fluid for burn resuscitation per the Parkland formula, restoring volume and electrolytes without causing hemolysis.