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When reviewing the arterial blood gas values for a client, a nurse notes a pH of 7.32, PaCO2 of 48 mm Hg, and HCO3 of 23 mEq/L. What does this indicate about the acid-base balance?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: A
Rationale: The given values suggest respiratory acidosis. In respiratory acidosis, the pH is low (<7.35), PaCO2 is high (>45 mm Hg), and the HCO3 is normal or slightly elevated. In this scenario, the low pH (7.32) and high PaCO2 (48 mm Hg) indicate respiratory acidosis, where there is an excess of carbon dioxide in the blood, leading to acidification of the body fluids.
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A patient calls and says she used her diaphragm on Saturday night at 8:00 p.m., again on Sunday morning at 2:00 a.m., and again at 8:00 a.m. She is wondering when she can safely remove it while still having effective contraception. What is the nurse’s best response?
- A. 10:00 a.m. Sunday
- B. 2:00 p.m. Sunday
- C. 10:00 p.m. Sunday
- D. 8:00 a.m. Monday
Correct Answer: D
Rationale: In general, a diaphragm should be left in place for at least 6 hours after intercourse but no more than 24 hours. Based on the patient's usage times on Saturday night at 8:00 p.m., Sunday morning at 2:00 a.m., and Sunday morning at 8:00 a.m., she can safely remove the diaphragm on Monday morning at 8:00 a.m. This ensures she has used it for the necessary timeframe for effective contraception.
The nurse is educating a G1P0 client who is 34 weeks in the third trimester. gestation and in her third trimester. Which of the
- A. I should gain 3.5 to 5 pounds in the first following educational topics would be appropriate trimester and 1 pound per week in the last two at this time? Select all that apply. trimesters.
- B. Contraception options after delivery
- C. I should gain 10 pounds in the first trimester,
- D. Group B strep (GBS) screen before onset of labor 10 pounds in the second trimester, and 10 pounds
Correct Answer: A
Rationale: I should gain 3.5 to 5 pounds in the first trimester and 1 pound per week in the last two trimesters.
A nurse is caring for a client who is in labor and has an epidural for pain control. Which of the following clinical ... effect of epidural anesthesia?
- A. Polyuria
- B. Hypertensi on
- C. Pruritus
- D. Dry mouth
Correct Answer: C
Rationale: Epidural anesthesia can result in some common side effects, one of which is pruritus (itching). Pruritus is a known side effect of the local anesthetics used in epidural anesthesia and is due to their effects on specialized receptors in the nervous system. Patients may experience itching, especially in the face, neck, and upper chest areas. Polyuria (increased urine output), hypertension (high blood pressure), and dry mouth are not typically associated side effects of epidural anesthesia.
The nurse is educating a patient on what constitutes IPV. What is an example of an act of IPV?
- A. child endangerment
- B. stalking
- C. workplace harassment
- D. legal allegations
Correct Answer: B
Rationale: Stalking is a deliberate act where the perpetrator repeatedly follows, harasses, or intimidates the victim, which can instill fear or threaten safety. It is recognized as a specific form of intimate partner violence (IPV).
A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PaCO2 68 mm Hg, Base excess -2, PaO2 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: The ABG values provided indicate respiratory acidosis. In respiratory acidosis, there is an increase in PaCO2 above the normal range (35-45 mm Hg) leading to a decrease in pH (<7.35). In this case, the pH is 7.22 (below normal) with an elevated PaCO2 of 68 mm Hg. The other values do not suggest metabolic acidosis (which would typically show low bicarbonate levels) or metabolic alkalosis. Therefore, the correct interpretation of the ABGs is respiratory acidosis.