Nokea
You are an emergency-room nurse caring for a trauma patient. Your patient has the following arterial blood gas results: pH 7.26, PaCO2 28, HCO3 11 mEq/L. How would you interpret these results?
- A. Respiratory acidosis with no compensation
- B. Metabolic alkalosis with a compensatory alkalosis
- C. Metabolic acidosis with no compensation
- D. Metabolic acidosis with a compensatory respiratory alkalosis
Correct Answer: D
Rationale: To interpret the given ABG results:
1. pH <7.35 indicates acidosis.
2. PaCO2 <35 indicates respiratory alkalosis.
3. HCO3 <22 indicates metabolic acidosis.
Therefore, the ABG results show metabolic acidosis (low pH, low HCO3) with compensatory respiratory alkalosis (low PaCO2). This means the body is trying to compensate for the metabolic acidosis by decreasing PaCO2 through hyperventilation. Option D is correct. Options A, B, and C are incorrect as they do not align with the ABG results and the principles of acid-base balance.
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After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching?
- A. . I dont drink milk because it gives me gas and diarrhea
- B. I have been taking digoxin every day for the last 15 years
- C. . I take sodium bicarbonate after every meal to prevent heartburn
- D. In hot weather, I sweat so much that I drink six glasses of water each day.
Correct Answer: C
Rationale: The correct answer is C because taking sodium bicarbonate after every meal can actually increase the risk of metabolic alkalosis due to its alkaline nature. Sodium bicarbonate can lead to an excessive build-up of bicarbonate in the bloodstream, causing alkalosis.
Choice A is not directly related to metabolic alkalosis. Choice B, taking digoxin, is unrelated to metabolic alkalosis as well. Choice D, drinking six glasses of water due to sweating, does not contribute to metabolic alkalosis as it helps maintain hydration and electrolyte balance.
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?
- A. Allergic reaction
- B. Bowel obstruction
- C. Catheter lumen occlusion
- D. Infection
Correct Answer: D
Rationale: The correct answer is D, infection. The client's symptoms of abdominal pain and feeling warm are indicative of a potential infection, which is a common complication of intraperitoneal therapy. Step-by-step rationale: 1. Abdominal pain can be a sign of peritonitis, an infection of the peritoneal cavity. 2. Feeling warm may indicate a fever, a common symptom of infection. 3. Prompt assessment and treatment of infection are crucial to prevent complications. Summary of other choices: A, allergic reaction - unlikely given the symptoms described; B, bowel obstruction - does not align with the symptoms provided; C, catheter lumen occlusion - not typically associated with abdominal pain and feeling warm.
A nurse is caring for a client who has the following laboratory results: potassium 3.4 mEq/L, magnesium 1.8 mEq/L, calcium 8.5 mEq/L, sodium 144 mEq/L. Which assessment should the nurse complete first?
- A. Depth of respirations
- B. Bowel sounds
- C. Grip strength
- D. Electrocardiography
Correct Answer: A
Rationale: The correct assessment for the nurse to complete first is A: Depth of respirations. Potassium and magnesium levels are crucial electrolytes that can affect cardiac function. Hypokalemia (low potassium) and hypomagnesemia (low magnesium) can lead to cardiac dysrhythmias. Checking the depth of respirations can provide valuable information on the client's respiratory status and potential respiratory distress due to electrolyte imbalances. This assessment takes precedence as addressing respiratory issues promptly is essential to prevent further complications. Assessing bowel sounds (B), grip strength (C), and electrocardiography (D) are important but not as immediate as assessing respiratory status in this scenario.
While assessing a clients peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 4-cm venous cord. How should the nurse document this finding?
- A. Grade 3 phlebitis at IV site
- B. infection at IV site
- C. Thrombosed area at IV site
- D. infiltration at IV site
Correct Answer: A
Rationale: The correct answer is A: Grade 3 phlebitis at IV site. This finding indicates inflammation of the vein due to irritants from the IV catheter, supported by red streak and palpable cord. Grade 3 phlebitis involves pain, redness, swelling, and palpable venous cord. Infection (B) typically presents with signs like pus, warmth, and fever. Thrombosis (C) involves a blood clot, not a palpable cord. Infiltration (D) is leakage of IV fluid into surrounding tissues, not related to palpable cord and red streak.
The nurse caring for a patient post colon resection is assessing the patient on the second postoperative day. The
nasogastric tube (NG) remains patent and continues at low intermittent wall suction. The IV is patent and infusing at
125 mL/hr. The patient reports pain at the incision site rated at a 3 on a 0-to-10 rating scale. During your initial shift
assessment, the patient complains of cramps in her legs and a tingling sensation in her feet. Your assessment indicates
decreased deep tendon reflexes (DTRs) and you suspect the patient has hypokalemia. What other sign or symptom
would you expect this patient to exhibit
- A. Diarrhea
- B. Dilute urine
- C. Increased muscle tone
- D. Joint pain
Correct Answer: B
Rationale: The correct answer is B: Dilute urine. Hypokalemia can lead to kidney dysfunction, causing the kidneys to excrete more water along with electrolytes, resulting in dilute urine. This is a manifestation of the body's attempt to compensate for low potassium levels by excreting excess water. The other choices are incorrect because: A) Diarrhea is more commonly associated with hyperkalemia, not hypokalemia. C) Increased muscle tone is not a typical sign of hypokalemia; rather, hypokalemia can lead to muscle weakness or paralysis due to impaired muscle function. D) Joint pain is not a typical symptom of hypokalemia; joint pain is more commonly associated with other conditions such as arthritis or inflammation.