Nokea
Which arterial blood gas (ABG) values should the nurse anticipate in the client with a nasogastric tube attached to continuous suction?
- A. pH 7.25, PaCO2 55, HCO3 24
- B. pH 7.30, PaCO2 38, HCO3 20
- C. pH 7.48, PaCO2 30, HCO3 23
- D. pH 7.49, PaCO2 38, HCO3 30
Correct Answer: D
Rationale: Continuous nasogastric suction can lead to metabolic alkalosis due to the loss of gastric acid (hydrochloric acid), which reduces hydrogen ions and increases bicarbonate levels. The ABG values in option 4 (pH 7.49, PaCO2 38, HCO3 30) indicate metabolic alkalosis, with an elevated pH and high bicarbonate level, consistent with this condition. Option 1 suggests respiratory acidosis, option 2 suggests metabolic acidosis, and option 3 suggests respiratory alkalosis, none of which align with the expected acid-base imbalance from nasogastric suction.
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The nurse who has been closely monitoring a child who has been exhibiting decorticate (flexor) posturing notes that the child suddenly exhibits decerebrate (extensor) posturing. The nurse interprets that this change in the child's posturing indicates what?
- A. An insignificant finding
- B. An improvement in condition
- C. Decreasing intracranial pressure
- D. Deteriorating neurological function
Correct Answer: D
Rationale: The progression from decorticate to decerebrate posturing usually indicates deteriorating neurological function and warrants primary health care provider notification. Options 1, 2, and 3 are inaccurate interpretations.
A client is admitted to the hospital with a diagnosis of Cushing's syndrome. The nurse monitors the client for which problem that is likely to occur with this diagnosis?
- A. Hypovolemia
- B. Hypoglycemia
- C. Mood disturbances
- D. Deficient fluid volume
Correct Answer: C
Rationale: Cushing's syndrome is a metabolic disorder resulting from the chronic and excessive production of cortisol. When Cushing's syndrome develops, the normal function of the glucocorticoids becomes exaggerated and the classic picture of the syndrome emerges. This exaggerated physiological action can cause mood disturbances, including memory loss, poor concentration and cognition, euphoria, and depression. It can also cause persistent hyperglycemia along with sodium and water retention (hypernatremia), producing edema (hypervolemia; fluid volume excess), and hypertension.
A client states, 'I'm sure I have restless leg syndrome.' The nurse determines that the client is in need of further teaching on the condition when the client identifies the presence of which characteristics? Select all that apply.
- A. A heavy feeling in the legs
- B. Burning sensations in the limbs
- C. Symptom relief when lying down
- D. Decreased ability to move the legs
- E. Symptoms that are worse in the morning
- F. Feeling the need to move the limbs repeatedly
Correct Answer: A,C,D,E
Rationale: Restless leg syndrome is characterized by leg paresthesia associated with an irresistible urge to move. The client complains of intense burning or 'crawling-type' sensations in the limbs and subsequently feels the need to move the limbs repeatedly to relieve the symptoms. The symptoms are worse in the evening and night when the client is still.
The nurse is caring for a client in active labor. Which intervention should the nurse implement to prevent fetal heart rate decelerations?
- A. Discourage the client from walking.
- B. Increase the rate of the oxytocin infusion.
- C. Monitor the fetal heart rate every 30 minutes.
- D. Encourage upright or side-lying maternal positions.
Correct Answer: D
Rationale: Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. There are many nursing actions to prevent fetal heart rate decelerations without necessitating surgical intervention.
The nurse is measuring the fundal height on a client who is 36 weeks' gestation when the client reports feeling lightheaded. What finding should the nurse expect to note when assessing the client?
- A. Fear
- B. Anemia
- C. A full bladder
- D. Compression of the vena cava
Correct Answer: D
Rationale: Compression of the inferior vena cava and aorta by the uterus may cause supine hypotension syndrome (vena cava syndrome) late in pregnancy. Having the client turn onto her left side or elevating the left buttock during fundal height measurement will prevent the problem. Options 1, 2, and 3 are unrelated to this syndrome.