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A patient who sustained massive internal injuries in a car crash becomes hypotensive and develops acute renal failure.
Which acid-base imbalance is he most likely to experience?
- A. Respiratory acidosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: Renal failure causes metabolic acidosis due to impaired acid excretion.
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The nurse on the floor will perform peripheral IV site insertion.
Her performance is based on:
- A. Hospital policies and procedures.
- B. Nursing Standards of Practice.
- C. Doctor's orders.
- D. IV regulation developed by the Board of Nursing
Correct Answer: B
Rationale: Nursing Standards of Practice guide safe and competent IV insertion.
For proper foot care, the nurse should provide a patient with non-insulin dependent mellitus with instructions to:
For proper foot care, the nurse should provide a patient with non-insulin dependent mellitus with instructions to:
- A. Remove all corns and stop smoking.
- B. Always wear shoes and use natural fiber socks.
- C. Wear nylon socks and wash feet in warm water.
- D. Wear shoes that are slightly larger and avoid corn removers.
Correct Answer: B
Rationale: Wearing shoes and natural fiber socks protects diabetic feet and promotes circulation.
A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene?
- A. Explain that she can't give medical advice
- B. Inform the neighbor that she might require surgery
- C. Advise the neighbor to seek medical attention
- D. Tell the neighbor that she'll be fine because she was able to get through the night
Correct Answer: C
Rationale: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.
The nurse is caring for an adult who has ulcerative colitis. When planning care, the nurse knows that which nursing diagnosis is of highest priority?
- A. Deficient fluid volume
- B. Disturbed body image
- C. Risk for impaired skin integrity
- D. Risk for ineffective health maintenance
Correct Answer: A
Rationale: Ulcerative colitis causes diarrhea, leading to fluid loss and dehydration, making deficient fluid volume the highest priority to prevent systemic complications like hypovolemia.
Which fetal heart monitor pattern can indicate cord compression?
- A. variable decelerations
- B. early decelerations
- C. bradycardia
- D. tachycardia
Correct Answer: A
Rationale: Variable decelerations are associated with umbilical cord compression, which can intermittently reduce fetal blood flow. The other patterns are related to different fetal conditions. Reduction of Risk Potential