Nokea
What do the following ABG values indicate: pH 7.38, PO2 78 mmHg, PCO2 36 mmHg, and HCO3 24 mEq/L?
- A. metabolic alkalosis
- B. homeostasis
- C. respiratory acidosis
- D. respiratory alkalosis
Correct Answer: B
Rationale: The correct answer is 'homeostasis.' These ABG values fall within the normal range, indicating a state of balance and homeostasis. The pH is within the normal range (7.35-7.45), the PCO2 is normal (35-45 mmHg), and the HCO3 level is also normal (22-26 mEq/L). Choice A, 'metabolic alkalosis,' is incorrect because the pH, PCO2, and HCO3 levels are not indicative of metabolic alkalosis. Choice C, 'respiratory acidosis,' is incorrect as the pH and PCO2 values are not elevated. Choice D, 'respiratory alkalosis,' is incorrect as the pH and PCO2 levels are not decreased. Therefore, the ABG values provided do not correspond to any acid-base disturbance, confirming that the patient is in a state of homeostasis.
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The client diagnosed with end-stage liver disease has completed an advance directive and a do-not-resuscitate (DNR) document and wishes to receive palliative care. Which of the following would correspond to the client's wish for comfort care?
- A. Positioning frequently to prevent skin breakdown and providing pain management and other comfort measures
- B. Carrying out vigorous resuscitation efforts if the client were to stop breathing, but no resuscitation if the heart stops beating
- C. Providing intravenous fluids when the client becomes dehydrated
- D. Providing total parenteral nutrition (TPN) if the client is not able to eat
Correct Answer: A
Rationale: Palliative care includes measures to prevent skin breakdown, pain management, and management of other symptoms that cause discomfort, as well as encouraging contact with family and friends. A DNR request precludes all resuscitative efforts related to respiratory or cardiac arrest, making choice B incorrect. Dehydration is a natural part of the dying process, so providing intravenous fluids as in choice C would not align with the client's wish for comfort care. Total parenteral nutrition (TPN) as in choice D is an invasive procedure meant to prolong life and is not part of palliative care, which focuses on improving quality of life rather than extending it.
Which of the following injuries, presented by a client entering the Emergency Department, is the highest priority?
- A. open leg fracture
- B. open head injury
- C. stab wound to the chest
- D. traumatic amputation of a thumb
Correct Answer: C
Rationale: A stab wound to the chest is the highest priority injury. This type of injury can lead to lung collapse and mediastinal shift, potentially resulting in death if left untreated. Treating an obstructed airway or a chest wound takes precedence over addressing hemorrhage. The principle of ABC (airway, breathing, and circulation) guides care decisions in prioritizing life-threatening situations. An open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate threat to life compared to a stab wound to the chest. An open leg fracture may lead to significant blood loss but is not immediately life-threatening. An open head injury requires assessment and intervention but does not impact airway, breathing, or circulation directly. Traumatic amputation of a thumb is a serious injury but can be managed after addressing more life-threatening conditions.
Why must the nurse be careful not to cut through or disrupt any tears, holes, bloodstains, or dirt present on the clothing of a client who has experienced trauma?
- A. The clothing may be potential evidence with legal implications.
- B. Such care facilitates the preservation of potential evidence.
- C. The clothing of a trauma victim can be used for further investigation.
- D. Such care maintains the integrity of the clothing for forensic analysis.
Correct Answer: C
Rationale: In cases of trauma, the clothing of a client can hold crucial evidence that may have legal implications. It is essential for the nurse to avoid cutting through or disrupting any tears, holes, bloodstains, or dirt present on the clothing to preserve this potential evidence. The correct answer highlights the legal importance of preserving the clothing for potential legal implications. Choice B is related but does not emphasize the legal aspect explicitly. Choice C is vague in mentioning further investigation without specifying the legal significance. Choice D focuses more on forensic analysis rather than the legal implications of preserving the clothing.
In alcoholics with anemia:
- A. Pernicious anemia is more common than folic acid deficiency.
- B. Iron deficiency and folic acid deficiency can coexist.
- C. The alcohol interferes with iron absorption.
- D. Oral vitamin replacement is contraindicated.
Correct Answer: B
Rationale: In alcoholics with anemia, iron deficiency and folic acid deficiency can coexist due to poor dietary intake and malabsorption issues associated with chronic alcohol consumption. Pernicious anemia, primarily related to vitamin B12 deficiency, is not commonly seen in alcoholics. While alcohol can interfere with iron absorption, it is not the sole factor contributing to anemia in alcoholics. Oral vitamin replacement is not contraindicated in alcoholics with anemia; however, it may be less effective due to absorption issues related to alcohol consumption.
A client is being taught about self-administration of Haldol 15 mg po hs. For which side effect/s should the client seek medical attention?
- A. Shortness of breath and fatigue
- B. Restlessness and muscle spasms
- C. Dry mouth
- D. Diarrhea
Correct Answer: B
Rationale: The correct answer is restlessness and muscle spasms. Haldol, an antipsychotic medication, can cause extrapyramidal side effects such as muscle spasms and restlessness. These side effects can be serious and should prompt the client to seek medical attention. Shortness of breath, fatigue, dry mouth, and diarrhea are not commonly associated with Haldol use, making choices A, C, and D incorrect.