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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 provides discharge instructions to a client beginning oral hypoglycemic therapy. Which statements if made by the client indicate a need for further teaching? Select all that apply.
- A. If I am ill, I should skip my daily dose.
- B. If I overeat, I will double my dosage of medication.
- C. Oral agents are effective in managing type 2 diabetes.
- D. If I become pregnant, I will discontinue my medication.
- E. Oral hypoglycemic medications will cause my urine to turn orange.
- F. My medications are used to manage my diabetes along with diet and exercise.
Correct Answer: A,B,D,E
Rationale: Clients are instructed that oral agents are used in addition to diet and exercise as therapy for diabetes mellitus. During illness or periods of intense stress, the client should be instructed to monitor her or his blood glucose level frequently and should contact the primary health care provider if the blood glucose is elevated because insulin may be needed to prevent symptoms of acute hyperglycemia. The medication should not be skipped or the dosage should not be doubled. Taking extra medication should be avoided unless specifically prescribed by the primary health care provider. Medication should never be discontinued unless instructed to do so by the primary health care provider. However, the diabetic who becomes pregnant will need to contact her primary health care provider because the oral diabetic medication may have to be changed to insulin therapy because some oral hypoglycemics can be harmful to the fetus. These medications do not change the color of the urine.
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 caring for a client with a nasogastric tube that is attached to low suction. If the client's HCO3- is 30, which additional value is most likely to be noted in this client?
- A. pH 7.52
- B. pH 7.36
- C. pH 7.25
- D. pH 7.20
Correct Answer: A
Rationale: Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis because of the loss of hydrochloric acid (HCl), an acid secreted in the stomach. This occurs as HCO3 rises above normal. Thus, the loss of hydrogen ions in the HCl results in alkalosis. A pH above 7.45 would be noted.
When a client with a chest injury is suspected of experiencing a pleural effusion, which typical manifestations of this respiratory problem should the nurse assess for? Select all that apply.
- A. Dry cough
- B. Moist cough
- C. Dyspnea at rest
- D. Productive cough
- E. Dyspnea on exertion
- F. Nonproductive cough
Correct Answer: A,E,F
Rationale: A pleural effusion is the collection of fluid in the pleural space. Typical assessment findings in the client with a pleural effusion include dyspnea, which usually occurs with exertion, and a dry, nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift.
When caring for a client diagnosed with myasthenia gravis, the nurse should be alert for which manifestations of myasthenic crisis? Select all that apply.
- A. Bradycardia
- B. Increased diaphoresis
- C. Decreased lacrimation
- D. Bowel and bladder incontinence
- E. Absent cough and swallow reflex
- F. Sudden marked rise in blood pressure
Correct Answer: B,D,E,F
Rationale: Myasthenic crisis is caused by undermedication or can be precipitated by an infection or sudden withdrawal of anticholinesterase medications. It may also occur spontaneously. Clinical manifestations include increased diaphoresis, bowel and bladder incontinence, absent cough and swallow reflex, sudden marked rise in blood pressure because of hypoxia, increased heart rate, severe respiratory distress and cyanosis, increased secretions, increased lacrimation, restlessness, and dysarthria.