Nokea
The nurse is reviewing the lab results of a client's arterial blood gases. The $\mathrm{PaCO}_2$ indicates effective functioning of the:
- A. Kidneys
- B. Pancreas
- C. Lungs
- D. Liver
Correct Answer: C
Rationale: PaCO2 reflects lung function, as the lungs regulate carbon dioxide levels through ventilation; abnormal levels indicate respiratory issues.
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A client has a CVP monitor in place. Which would be included in the nursing care plan for this client?
- A. Notify the physician of readings less than 3 cm or more than 8 cm of water
- B. Use the clean technique to change the dressing at the insertion site
- C. Elevate the head of the bed to 90° to obtain CVP readings
- D. The 0 mark on the manometer should align with the client's right clavicle for the readings
Correct Answer: A
Rationale: CVP readings outside 3-8 cm of water may indicate fluid imbalance or catheter issues, requiring physician notification to prevent complications.
An ICU nurse monitors a client recovering from a head injury. The client's intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client's endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
- A. increase the rate of the sedative IV drip.
- B. chart the findings and continue to monitor the client.
- C. reposition the client.
- D. contact the physician.
Correct Answer: D
Rationale: A sudden ICP spike to 28 mmHg post-suctioning suggests a significant issue (e.g., impaired cerebral perfusion). The physician should be contacted for evaluation.
A burn client begins treatments with silver sulfadiazine (Silvadene) applied to the wounds. The nurse should carefully monitor for which adverse affect associated with this drug?
- A. Hypokalemia
- B. Leukopenia
- C. Hyponatremia
- D. Thrombocytopenia
Correct Answer: B
Rationale: Silver sulfadiazine can cause leukopenia as an adverse effect, requiring monitoring of white blood cell counts to detect potential bone marrow suppression.
A client's lab results have just come in. The nurse reviews the electrolytes and contacts the health care provider regarding which result?
- A. chloride 167 mEq/L
- B. calcium 9.3 mg/dL
- C. phosphate 3.8 mg/dL
- D. sodium 141 mEq/L
Correct Answer: A
Rationale: Chloride 167 mEq/L is severely elevated (normal 98-106 mEq/L), requiring immediate attention. Other values are normal.
A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS?
- A. High calorie, high protein, high fat
- B. High calorie, high carbohydrate, low protein
- C. High calorie, low carbohydrate, high fat
- D. High calorie, high protein, low fat
Correct Answer: D
Rationale: A high-calorie, high-protein, low-fat diet helps maintain weight and muscle mass in clients with AIDS while minimizing gastrointestinal complications.