Nokea
The nurse is teaching a patient about the administration of liquid iron supplements. Which response by the patient indicates the need for additional teaching?
- A. I will take my iron supplement with a straw.
- B. I will take my iron supplement at bedtime.
- C. I will take my iron supplement along with meals.
- D. I will take my iron supplement along with orange juice.
Correct Answer: C
Rationale: Taking iron supplements with meals decreases absorption, indicating a need for further teaching; iron should be taken on an empty stomach or with vitamin C.
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A patient with chronic obstructive pulmonary disease (COPD) has the following arterial blood gas (ABG) results: a blood pH of 7.29, a partial pressure of carbon dioxide (PaCO2) level of 49 mm Hg, and a bicarbonate ion (HCO3) level of 25 mEq/L. Which condition would the nurse have in mind when developing the patient's plan of care?
- A. Metabolic acidosis.
- B. Metabolic alkalosis.
- C. Respiratory acidosis.
- D. Respiratory alkalosis.
Correct Answer: C
Rationale: Respiratory acidosis is indicated by low pH (7.29) and high PaCO2 (49 mm Hg), common in COPD due to impaired CO2 elimination.
Which rationale supports the nurse's assessment of a patient's magnesium level?
- A. The electrolyte is the most abundant intracellular cation present in the body.
- B. The electrolyte may cause extracellular fluid overload.
- C. Magnesium may affect neuromuscular excitability and contractility.
- D. The patient is at risk for hypotension when the levels of magnesium decrease.
Correct Answer: C
Rationale: Magnesium plays a crucial role in neuromuscular excitability and contractility. Abnormal magnesium levels can lead to neuromuscular symptoms such as muscle weakness, tremors, and spasms, and affect cardiac function.
A patient's arterial blood gas (ABG) results include a pH of 7.32, a PaCO2 of 56 mm Hg, and an HCO3 of 24 mEq/L. Which acid-base imbalance would the nurse use when developing the patient's plan of care?
- A. Metabolic acidosis.
- B. Metabolic alkalosis.
- C. Respiratory acidosis.
- D. Respiratory alkalosis.
Correct Answer: C
Rationale: Respiratory acidosis is characterized by low pH (7.32) and high PaCO2 (56 mm Hg), with normal HCO3 indicating no metabolic compensation.
The nurse receives information about the assigned patients during shift report. Which patient would the nurse assess first?
- A. A patient who reports dizziness with a blood pressure (BP) of 150/92 mm Hg.
- B. A patient who reports a severe headache and has begun vomiting.
- C. A patient with a hip fracture who reports a pain level of 2 on a 1-to-10 scale.
- D. A patient who received an angiotensin-converting enzyme (ACE) inhibitor 30 minutes previously and reports fatigue.
Correct Answer: B
Rationale: A severe headache and vomiting could be indicative of a serious neurological condition such as a stroke, intracranial bleeding, or increased intracranial pressure. This patient needs urgent assessment and intervention to prevent potential complications.
Which treatment is likely to be planned for a patient who develops pernicious anemia after a gastrectomy?
- A. Triple-drug therapy.
- B. IV therapy.
- C. Quadruple-drug therapy.
- D. Cobalamin replacement therapy.
Correct Answer: D
Rationale: Cobalamin replacement therapy is the standard treatment for pernicious anemia caused by vitamin B12 deficiency due to lack of intrinsic factor post-gastrectomy.