Nokea
The nurse is assessing the arterial blood gases (ABG) of a chest trauma client with the results of pH 7.35, PO2 85, PCO2 55, and HCO3 27. These ABG values indicate that the client is in:
- A. Uncompensated respiratory acidosis
- B. Uncompensated metabolic acidosis
- C. Compensated respiratory acidosis
- D. Compensated metabolic acidosis
Correct Answer: C
Rationale: pH 7.35 is normal, PCO2 55 is elevated (indicating respiratory acidosis), and HCO3 27 is slightly elevated, suggesting compensation. This is compensated respiratory acidosis, likely due to hypoventilation from chest trauma.
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A client with bipolar disorder is taking lithium to control symptoms. Which of the following statements indicates the need for further education?
- A. I need to have regular tests for thyroid function.
- B. Once I'm stabilized, I won't need further testing.
- C. I should avoid taking ibuprofen.
- D. It's important for me to avoid dehydration.
Correct Answer: B
Rationale: Lithium requires ongoing monitoring (B is incorrect), as levels and side effects need regular checks. Thyroid tests (A), avoiding ibuprofen (C), and hydration (D) are correct.
A client admitted with hepatic encephalopathy continues to attempt ambulation without assistance despite repeated instruction. Which intervention should the nurse take to promote safety?
- A. administer Xanax 6 mg PO
- B. apply a vest restraint device
- C. request a family member stay with the client around the clock
- D. move the client closer to the nurses' station
Correct Answer: D
Rationale: Moving the client closer to the nurses’ station allows frequent monitoring, promoting safety without restraints or sedation, which are less appropriate.
A home health nurse is visiting a client who is receiving diuretic therapy for congestive heart failure. Which medication places the client at risk for the development of hypokalemia?
- A. Aldactone (spironolactone)
- B. Demadex (torsemide)
- C. Dyrenium (triamterene)
- D. Midamor (amiloride hydrochloride)
Correct Answer: B
Rationale: Demadex, a loop diuretic, causes potassium loss, increasing the risk of hypokalemia, unlike potassium-sparing diuretics like Aldactone.
The nurse is teaching the client with AIDS regarding needed changes in food preparation. Which statement indicates that the client understands the nurse's teaching?
- A. Adding fresh ground pepper to my food will improve the flavor.
- B. Meat should be thoroughly cooked to the proper temperature.
- C. Eating cheese and yogurt will prevent AIDS-related diarrhea.
- D. It is important to eat four to five servings of fresh fruits and vegetables a day.
Correct Answer: B
Rationale: Thoroughly cooking meat reduces the risk of foodborne infections, which is critical for clients with AIDS due to their weakened immune systems.
A client is admitted with disseminated herpes zoster. According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions due to the risk of varicella-zoster virus transmission through respiratory droplets and contact.