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The nurse is caring for a client who presents to the ED with the following arterial blood gas (ABG) results: pH 7.32, PaCO2 47 mm Hg, HCO3 24 mEq/L, PaO2 91 mm Hg. Which clinical manifestation would the nurse anticipate, based on these findings?
- A. confusion
- B. nausea and vomiting
- C. deep, rapid respirations
- D. hypoventilation with hypoxia
Correct Answer: A
Rationale: The ABG results (pH 7.32, PaCO2 47) indicate uncompensated respiratory acidosis. Confusion (A) is a common symptom due to CO2 retention. Deep, rapid respirations (C) are compensatory for metabolic acidosis, not respiratory. Nausea (B) and hypoventilation (D) are less specific.
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A nurse is providing pre-op teaching to a client who will be undergoing a coronary artery bypass graft. Which of the following should the nurse include in the teaching? Select all that apply.
- A. Your medications will be changed after surgery.
- B. You will be on strict bed rest for the first 48 hours.
- C. You will be using a bedpan after surgery to urinate.
- D. You will need to splint the chest incision when you cough or breathe deeply.
- E. You will be on the ventilator after surgery and have one or more chest tubes.
Correct Answer: A,D,E
Rationale: Medication changes (A), splinting the incision (D), and ventilator/chest tubes (E) are standard post-CABG. Bed rest is not strict (B), and bedpans (C) are not always required.
The oncology nurse is assessing a client diagnosed with cancer of the tongue. Upon examination, which signs and symptoms would the nurse expect to find? Select all that apply.
- A. weight gain
- B. well-fitting dentures
- C. a black, hairy tongue
- D. difficulty swallowing
- E. a sore that bleeds or does not heal
- F. difficulty chewing or pain with chewing
Correct Answer: D,E,F
Rationale: Tongue cancer causes difficulty swallowing (D), non-healing/bleeding sores (E), and chewing pain (F). Weight gain (A), well-fitting dentures (B), and black hairy tongue (C) are unrelated.
The nurse comes upon a client in the clinic who appears to have experienced a sudden cardiac arrest. After retrieving the automated external defibrillator (AED), the nurse knows to use the equipment in the following manner, as per the American Red Cross. List the steps in order. Use all the steps.
- A. Make sure no one is touching the client. Tell everyone to 'stand clear.'
- B. Open the person's shirt and wipe the chest dry. Remove any visible patches.
- C. Attach the AED pads and plug in the connector.
- D. Push the 'analyze' button to analyze the client's heart rhythm.
- E. Turn on AED. Follow visual and/or audio prompts.
- F. Begin CPR.
- G. As prompted, press the 'shock' button after clearing the client.
Correct Answer: E,B,C,D,A,G
Rationale: Turn on AED (E), prepare chest (B), attach pads (C), analyze rhythm (D), clear client (A), shock (G), then resume CPR per American Red Cross guidelines.
The nurse is assessing a client with Parkinson's disease. Which sign of primary motor symptom involvement would the nurse expect to observe?
- A. resting tremor
- B. sleep disturbance
- C. constipation
- D. fatigue
Correct Answer: A
Rationale: Resting tremor (A) is a primary motor symptom of Parkinson's. Sleep disturbance (B), constipation (C), and fatigue (D) are non-motor symptoms.
The nurse notes irritability, microcephaly, and short palpebral fissures in a newborn in the nursery. The nurse suspects which diagnosis for this infant?
- A. syphilis
- B. TORCH syndrome
- C. brachial plexus injury
- D. fetal alcohol syndrome (FAS)
Correct Answer: D
Rationale: Irritability, microcephaly, and short palpebral fissures are classic signs of fetal alcohol syndrome (D). Syphilis (A) causes rash/bone defects, TORCH (B) varies by infection, and brachial plexus injury (C) affects arm movement.