a client has the following arterial blood gas results pH 7.30, HCO3 17 mEq/L, PaCO2 25 mm Hg. which intervention by the nurse is most important?
a.
... [Show More] prepare to administer the ordered albuterol nebulizer treatment b. place the client on 2L oxygen via nasal cannula
c. assess the client and notify the physician using SBAR
d. these are normal finding, document and continue to assess
- ANSWER-c. assess the client and notify the physician using SBAR
the nurse is to administer ampicillin 500 mg orally to a client with ruptured appendix the nurse checks the capsule in the client medication box located inside the clients room. the medication dosage is not labeled but the nurse recognizes the color and shape of the capsule. which of the following should the nurse do next?
a. administer the medication to maintain blood levels of the drug
b. ask another registered nurse (RN) to verify the capsule is ampicillin c. notify the unit manager to report the problem
d. contact the pharmacy to bring a properly labeled medication
- ANSWER-d. contact the pharmacy to bring a properly labeled medication
a client with a serum sodium level of 113 mEq/L has been receiving 3% sodium chloride IV infusion at 50 mL/hr for 16 hours. the client feels tired and short of breath. which of the following is the priority?
a. notify the physician
b. obtain order to decrease infusion c. assess for signs of fluid overload
d. check the latest sodium level
- ANSWER-c. assess for signs of fluid overload
a nurse is providing teaching for a client who has experienced an acute episode of gastritis. which of the following instructions should the nurse include in the teaching?
a. limit drinking milk
b. limit strenuous exercise c. avoid drinking alcohol
d. take nonsteroidal anti-inflammatory drugs (NSAIDs) for pain
- ANSWER-c. avoid drinking alcohol
which client being managed for dehydration does the nurse consider at greatest risk for possible reduced kidney function?
a. a 45-year old man receiving oral and IV fluid therapy
b. a 48-year old woman with established urinary continence c. a 62-year old woman with a known allergy to contrast media
d. an 80-year old man who has benign prostatic hyperplasia
- ANSWER-d. an 80-year old man who has benign prostatic hyperplasia
immediately after having surgery to create an ileostomy, which goal has the highest priority?
a. minimizing odor formation
b. providing relief from constipation
c. maintaining fluid and electrolyte balance
d. assisting the client with self-care activities
- ANSWER-c. maintaining fluid and electrolyte balance
the nurse is caring for a client with a bleeding duodenal ulcer who was admitted to the hospital after vomiting bright red blood. which condition does the nurse anticipate when the client develops a sudden, sharp pain in the mid-epigastric region and a rigid, board- like abdomen
a. pancreatitis
b. ulcer perforation
c. small bowel obstruction
d. development of additional ulcers
- ANSWER-b. ulcer perforation
a client is receiving 250 mL of 3% sodium chloride solution intravenously for severe hyponatremia. which signs or symptoms indicate to the nurse that this therapy is effective?
a. blood pressure has increased from 100/50 mm Hg to 112/70 mm Hg b. the client reports hand swelling
c. fall sounds are present in all four abdominal quadrants
d. serum potassium levels have decreased 4.4 mEq/L to 4.2 mEq/L
- ANSWER-a. blood pressure has increased from 100/50 mm Hg to 112/70 mm Hg
the nurse is evaluating the arterial blood gas ABG results of her clients. which of the following ABG results exhibits partially compensated respiratory alkalosis?
a. pH 7.24, PaCO2 33 mmHg, HCO3-26 mEq/L b. pH 7.33, PaCO2 55 mmHg, HCO3- 30 mEq/L c. pH 7.55, PaCO2 30 mmHg, HCO3-19 mEq/L
d. pH 7.50, PaCO2 50 mm Hg, HCO3- 38 mEq/L
- ANSWER-c. pH 7.55, PaCO2 30 mmHg, HCO3 19 mEq/L
the nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. which item should the nurse include on the list?
a. non-fat milk
b. scrambled eggs c. chocolate
d. baked chicken - ANSWER-c. chocolate
the nurse is evaluating the fluid volume status of a client after ileostomy surgery which finding indicates that adequate fluid replacement has been achieved in the client?
a. an increase in body weight
b. fluid intake less than urinary output c. urine output greater than 30 mL/hr
d. blood pressure of 90/40 mm Hg
- ANSWER-c. urine output greater than 30 mL/hr
a client has the following arterial blood gas (ABG) results: pH 7.30, HCO3 -22 mEq/L, PaCO2 67 mm Hg, Pa02 66 mm Hg. which intervention by the nurse takes priority?
a. assess the client's airway b. administer a bronchodilator c. administer mucolytic
d. provide oxygen via nasal cannula
- ANSWER-a. assess the client's airway
a client with a calcium level of 14 mg/dL is being cared for on the medical unit. nursing actions included in the care plan will include which of the following?
a. monitoring for a bounding pulse
b. encouraged increased fluid intake daily c. auscultating lung sounds every 4 hrs
d. maintaining the client on bed rest
- ANSWER-b. encouraging increased fluid intake daily
a client is admitted to the emergency room with a respiratory rate of 6 bpm, ABG's have been drawn and revealed the following values of pH 7.22, PaCO2 68 mmHg, HCO3-25 mEq/L. which of the following is an appropriate analysis of these ABG's?
a. uncompensated respiratory acidosis
b. partially compensated metabolic alkalosis c. uncompensated metabolic acidosis
d. partially compensated respiratory alkalosis
- ANSWER-a. uncompensated respiratory acidosis
the nurse is assessing the client who has started to complain of muscle cramps and paresthesia in his hands and feet. the nurse notes positive chvostek's sign upon assessment and knows this result is associated with which electrolyte disorder?
a. hyperkalemia b. hypocalcemia
c. hypophosphatemia
d. hypercalcemia
- ANSWER-b. hypocalcemia [Show Less]