Nokea
The nurse is reviewing the client's arterial blood gas results. Which finding would indicate that the client is experiencing respiratory acidosis?
- A. pH 7.5, PcO2 of 30
- B. pH 7.3, PcO2 of 50
- C. pH 7.3, HCO3 of 19
- D. pH 7.5, HCO3 of 30
Correct Answer: B
Rationale: In respiratory acidosis, the pH is decreased and an opposite effect is seen in the PCO2 (pH decreased, PCO2 elevated). Option 1 indicates respiratory alkalosis; option 3 indicates possible metabolic acidosis; option 4 indicates possible metabolic alkalosis.
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The nurse reviews the client's laboratory report to determine the client's blood level of valproic acid (Depakene), which is 35 mcg/mL. Based on this report, what should the nurse do first?
- A. Withhold the next dose of valproic acid.
- B. Notify the physician.
- C. Give the next dose as ordered.
- D. Take the client's vital signs.
Correct Answer: B
Rationale: A valproic acid level of 35 mcg/mL is below the therapeutic range (50-100 mcg/mL), indicating a need to notify the physician for potential dose adjustment.
A client with a history of heart failure is prescribed metoprolol (Lopressor). The nurse should monitor the client for which of the following adverse effects?
- A. Bradycardia.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Metoprolol, a beta-blocker, can cause bradycardia, requiring heart rate monitoring.
The nurse applies warm compresses to a client's leg. To determine effectiveness of the compresses, the nurse should determine if there is:
- A. Less scaling on the skin.
- B. Decreased bruising.
- C. Improved circulation to the area.
- D. Decreased swelling in the area.
Correct Answer: C
Rationale: Warm compresses promote vasodilation, improving circulation to the area, which aids healing and reduces symptoms.
A client whose condition remains stable after a myocardial infarction gradually increases his activity. Which of the following conditions should the nurse assess to determine whether the activity is appropriate for the client?
- A. External.
- B. Cyanosis.
- C. Dyspnea.
- D. Weight loss.
Correct Answer: C
Rationale: Dyspnea indicates inadequate oxygenation, suggesting the activity level may be too strenuous for the client's cardiac capacity post-myocardial infarction.
A nurse is caring for a client with a suspected myocardial infarction. Which of the following laboratory results should the nurse prioritize?
- A. Elevated troponin levels
- B. Decreased hemoglobin
- C. Increased potassium
- D. Elevated white blood cell count
Correct Answer: A
Rationale: Troponin is a specific marker for myocardial damage and is critical in diagnosing myocardial infarction. Other results are less specific to this condition.