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The nurse obtains a sample of a client's arterial blood gas (ABGs). Which of the following statements is NOT true about ABGs?
- A. Interpretation of the clients ABGs involves evaluation of pH, PCO2 and HCO3; components of the ABGs.
- B. ABGs assess the client oxygenation status and acid base status.
- C. ABGs provide information on blood parameters.
- D. ABGs asses the client electrolyte and fluid balance.
Correct Answer: D
Rationale: Arterial blood gases (ABGs) do not directly assess the client's electrolyte and fluid balance. ABGs primarily evaluate the client's acid-base balance and oxygenation status by measuring levels of pH, partial pressure of carbon dioxide (PCO2), and bicarbonate (HCO3) in the arterial blood. While ABGs can provide some information about blood parameters, such as oxygen saturation, they do not comprehensively assess electrolyte levels or fluid balance. To specifically assess electrolytes and fluid balance, additional tests like basic metabolic panels or comprehensive metabolic panels would be required.
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Mang Emilio refuses to take his daily medication for hypertension. Which of the following actions should Nurse Pedrito take at this time?
- A. Tell MangEmilio that he will suffer from stroke.
- B. Explore the reason for the client's refusal to take the medication.
- C. Administer the medication by injection.
- D. Obtain help from relatives in administering the medication.
Correct Answer: B
Rationale: The most appropriate action for Nurse Pedrito to take at this time is to explore the reason for Mang Emilio's refusal to take his daily medication for hypertension. By understanding the underlying cause of his refusal, Nurse Pedrito can address any concerns or barriers that may be preventing Mang Emilio from adhering to his medication regimen. This approach emphasizes the importance of patient-centered care and communication in promoting medication compliance and overall health outcomes. Additionally, it allows Nurse Pedrito to work collaboratively with Mang Emilio to find a solution that meets his needs and preferences.
A pregnant woman presents with severe abdominal pain and syncope at 6 weeks gestation. On examination, she has signs of hypovolemic shock. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Threatened abortion
- C. Placenta previa
- D. Gestational trophoblastic disease
Correct Answer: A
Rationale: In a pregnant woman presenting with severe abdominal pain, syncope, signs of hypovolemic shock, and gestational age of 6 weeks, the most likely cause is an ectopic pregnancy. An ectopic pregnancy occurs when a fertilized egg implants outside the uterus, commonly in the fallopian tube. As the pregnancy grows and the tube stretches, it can lead to rupture, causing severe abdominal pain, internal bleeding, and signs of shock. This is a life-threatening emergency that requires prompt diagnosis and management. It is important to consider ectopic pregnancy in any pregnant woman presenting with abdominal pain and signs of shock, especially in the first trimester.
A health care provider instructs the nurse to bladder train a patient. The nurse clamps the patient's indwelling urinary catheter but forgets to unclamped it. The patient develops a urinary tract infection. What do the nurse's actions' exemplify ?
- A. Malpractice
- B. Assault
- C. Battery
- D. Negligence
Correct Answer: D
Rationale: The nurse's actions exemplify negligence. Negligence is a failure to provide reasonable care that results in harm to a patient. In this scenario, the nurse failed to unclamp the patient's indwelling urinary catheter as instructed by the healthcare provider. This failure to follow proper procedure led to the patient developing a urinary tract infection, which could have been prevented if the nurse had acted with reasonable care. This action does not meet the criteria for malpractice, assault, or battery as those involve intentional harm or professional misconduct, whereas negligence involves a lack of appropriate care or attention.
A nurse is preparing to assist with a percutaneous endoscopic gastrostomy (PEG) tube insertion for a patient requiring long-term enteral feeding. What action should the nurse prioritize to ensure procedural success?
- A. Confirming the patient's fasting status before the PEG tube insertion
- B. Positioning the patient in a supine position with the head of the bed elevated
- C. Administering prophylactic antibiotics to prevent infection
- D. Coordinating with radiology or gastroenterology for procedural guidance Dermatology
Correct Answer: D
Rationale: Coordinating with radiology or gastroenterology for procedural guidance is crucial to ensure the success of a percutaneous endoscopic gastrostomy (PEG) tube insertion. This procedure is typically performed under endoscopic guidance to ensure proper placement of the tube into the stomach through the abdominal wall. Radiology or gastroenterology professionals are trained to perform and guide the insertion procedure, making their involvement essential for a successful outcome. Additionally, their expertise helps minimize the risk of complications during and after the PEG tube placement.
When a patient is diagnosed to have pneumonia, the breath sounds detected by the nurse on auscultation of the affected area would be ______.
- A. wheezing sounds
- B. fine crackles
- C. stridor
- D. deep and low-pitched breath sounds
Correct Answer: B
Rationale: When a patient is diagnosed with pneumonia, the breath sounds detected by the nurse on auscultation of the affected area would typically include fine crackles. Fine crackles are discontinuous, high-pitched crackling or rattling sounds heard during inspiration that indicate the presence of fluid in the small airways or alveoli. These crackles are caused by the movement of secretions or exudate within the bronchioles or alveoli, which is a common characteristic of pneumonia. Wheezing sounds are usually associated with conditions such as asthma, bronchitis, or COPD and are caused by narrowed airways. Stridor is a high-pitched, crowing sound that typically indicates an obstruction in the upper airway and is often heard in cases of laryngeal inflammation or foreign body aspiration. Deep and low-pitched breath sounds are more characteristic of conditions like chronic bronchitis.