Nokea
Which of the following laboratory results would suggest to the emergency room nurse that a client admitted after a severe motor vehicle crash is in acidosis?
- A. Hemoglobin 15 gm/dl
- B. Chloride 100 mEq/L
- C. Sodium 130 mEq/L
- D. Carbon dioxide 20 mEq/L
Correct Answer: D
Rationale: Serum carbon dioxide is an indicator of acid-base status. This finding would indicate acidosis.
You may also like to solve these questions
The nurse is caring for a client with a nasogastric tube.
- A. What is the most appropriate action for the nurse to take if the nasogastric tube appears occluded?
- B. Replace the nasogastric tube.
- C. Irrigate the tube with warm saline.
- D. Advance the tube 3-5 cm.
- E. Reposition the client to the left side.
Correct Answer: B
Rationale: Irrigating the nasogastric tube with warm saline is the first step to clear an occlusion, restoring function. Replacing the tube is invasive, advancing it risks misplacement, and repositioning does not address the occlusion directly.
A client with a hiatal hernia.
A nursing assessment of a client with a hiatal hernia is MOST likely to reveal
- A. a bulge in the lower right quadrant.
- B. pain at the umbilicus radiating down into the groin.
- C. a burning sensation in the midepigastric area each day before lunch.
- D. complaints of awakening at night with heartburn.
Correct Answer: D
Rationale: Strategy: Think about each answer choice. (1) suggests an inguinal hernia (2) suggests an inguinal hernia (3) pain usually does not develop during the day with an empty stomach (4) correct-classic symptom of hiatal hernia associated with reflux
When a client is having a general tonic clonic seizure, the nurse should
- A. Hold the client's arms at their side
- B. Place the client on their side
- C. Insert a padded tongue blade in client's mouth
- D. Elevate the head of the bed
Correct Answer: B
Rationale: Place the client on their side. This position maintains a patent airway and prevents aspiration.
A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would anticipate which of the following assessment findings?
- A. Hypotension, backache, low back pain, fever.
- B. Wet breath sounds, severe shortness of breath.
- C. Chills and fever occurring about an hour after the infusion started.
- D. Urticaria, itching, respiratory distress.
Correct Answer: A
Rationale: signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea, cyanosis, chest pains, tachycardia, and hypotension
The nurse is caring for a client with a fractured femur in traction.
- A. What is the most appropriate action for the nurse if the client reports numbness in the affected leg?
- B. Reposition the traction weights.
- C. Check the pin sites for infection.
- D. Assess the neurovascular status of the leg.
- E. Administer pain medication as ordered.
Correct Answer: C
Rationale: Numbness in the affected leg suggests possible neurovascular compromise, requiring immediate assessment of circulation, sensation, and motor function. Adjusting traction, checking pin sites, or giving pain medication does not address the urgent need to evaluate neurovascular status.