Nokea
The nurse reviews the client's most recent blood gas results that include a pH of 7.43, PCO2 of 31 mm Hg, and HCO3 of 21 mEq/L. Based on these results, the nurse determines that which acid-base imbalance is present?
- A. Compensated metabolic acidosis
- B. Compensated respiratory alkalosis
- C. Uncompensated respiratory acidosis
- D. Uncompensated metabolic alkalosis
Correct Answer: B
Rationale: The normal pH is 7.35 to 7.45, the normal PCO2 is 35 to 45 mm Hg, and the normal HCO3 is 22 to 27 mEq/L. The pH is elevated in alkalosis and low in acidosis. In a respiratory condition, the pH and the PCO2 move in opposite directions; that is, the pH rises and the PCO2 drops (alkalosis) or vice versa (acidosis). In a metabolic condition, the pH and the bicarbonate move in the same direction; if the pH is low, the bicarbonate level will be low also. In this client, the pH is at the high end of normal, indicating compensation and alkalosis. The PCO2 is low, indicating a respiratory condition (opposite direction of the pH).
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A client, admitted to the hospital for evaluation of recurrent runs of ventricular tachycardia, is scheduled for electrophysiology studies (EPS). Which statement should the nurse include in a teaching plan for this client?
- A. You will continue to take your medications until the morning of the test.
- B. You will be sedated during the procedure and will not remember what has happened.
- C. This test is a noninvasive method of determining the effectiveness of your medication regimen.
- D. The test uses a special wire to increase the heart rate and produce the irregular beats that cause your signs and symptoms.
Correct Answer: D
Rationale: The purpose of EPS is to study the heart's electrical system. During this invasive procedure, a special wire is introduced into the heart to produce dysrhythmias. To prepare for this procedure, the client should be NPO for 6 to 8 hours before the test, and all antidysrhythmics are held for at least 24 hours before the test to study the dysrhythmias without the influence of medications. Because the client's verbal responses to the rhythm changes are extremely important, sedation is avoided if possible.
The nurse is caring for a client with a diagnosis of pemphigus vulgaris. On assessment of the client, the nurse should look for which sign characteristic of this condition?
- A. Turner's sign
- B. Chvostek's sign
- C. Nikolsky's sign
- D. Trousseau's sign
Correct Answer: C
Rationale: A hallmark sign of pemphigus vulgaris is Nikolsky's sign, which occurs when the epidermis can be rubbed off by slight friction or injury. Other characteristics include flaccid bullae that rupture easily and emit a foul-smelling drainage, leaving crusted, denuded skin. The lesions are common on the face, back, chest, and umbilicus. Even slight pressure on an intact blister may cause spread to adjacent skin. Turner's sign refers to a grayish discoloration of the flanks and is seen in clients with acute pancreatitis. Chvostek's sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau's sign is a sign for tetany, in which carpal spasm can be elicited by compressing the upper arm with a blood pressure cuff inflated above the systolic pressure and causing ischemia to the nerves distally.
The nurse is applying electrocardiogram (ECG) electrodes to a diaphoretic client. Which intervention should the nurse take to keep the electrodes securely in place?
- A. Secure the electrodes with adhesive tape.
- B. Place clear, transparent dressings over the electrodes.
- C. Apply lanolin to the skin before applying the electrodes.
- D. Cleanse the skin with alcohol before applying the electrodes.
Correct Answer: D
Rationale: Alcohol defats the skin and helps the electrodes adhere to the skin. Placing adhesive tape or a clear dressing over the electrodes will not help the adhesive gel of the actual electrode make better contact with the diaphoretic skin. Lanolin or any other lotion makes the skin slippery and prevents good initial adherence.
The nurse is preparing to provide postsurgical care for a client after a subtotal thyroidectomy. The nurse anticipates the need for which item to be placed at the bedside to minimize the client's risk for injury?
- A. Hypothermia blanket
- B. Emergency tracheostomy kit
- C. Magnesium sulfate in a ready-to-inject vial
- D. Ampule of saturated solution of potassium iodide
Correct Answer: B
Rationale: Respiratory distress can occur after thyroidectomy as a result of swelling in the tracheal area. The nurse would ensure that an emergency tracheostomy kit is available. Surgery on the thyroid does not alter the heat control mechanism of the body. Magnesium sulfate would not be indicated because the incidence of hypomagnesemia is not a common problem after thyroidectomy. Saturated solution of potassium iodide is typically administered preoperatively to block thyroid hormone synthesis and release and to place the client in a euthyroid state.
To monitor for a temporary but common postsurgical complication of a transsphenoidal resection of the pituitary gland, the nurse should regularly perform which assessment?
- A. Pulse rate
- B. Temperature
- C. Urine output
- D. Oxygen saturation
Correct Answer: C
Rationale: A common complication of surgery on the pituitary gland is temporary diabetes insipidus. This results from a deficiency in antidiuretic hormone (ADH) secretion as a result of surgical trauma. The nurse measures the client's urine output to determine whether this complication is occurring. Polyuria of 4 to 24 L per day is characteristic of this complication. Options 1, 2, and 4 are not specifically related to a common complication after this surgery.