1.
Mang Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood gas results: partial pressure of oxygen (PO2). 55 mm Hg. and partial pressure of carbon dioxide (PCO2). 60 mm Hg. When attempting to improve the client’s blood gas values through improved ventilation and oxygen therapy. which is the client’s primary stimulus for breathing?
Correct Answer
B. Low PO2
Explanation
The client's primary stimulus for breathing is low PO2. In individuals with chronic obstructive pulmonary disease (COPD), the ability to exchange oxygen and carbon dioxide in the lungs is impaired. This leads to low levels of oxygen in the blood (low PO2). The body responds to this low oxygen level by increasing the respiratory rate and depth of breathing in order to improve oxygenation. Therefore, low PO2 acts as the primary stimulus for breathing in this client.
2.
A client with very dry mouth. skin and mucous membranes is diagnosed of having dehydration. Which intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?
Correct Answer
A. Assessing urinary intake and output
Explanation
The nurse should assess the client's urinary intake and output when caring for a client diagnosed with fluid volume deficit. This is because monitoring urinary output is an important indicator of hydration status and kidney function. By assessing urinary intake and output, the nurse can determine if the client is adequately hydrated or if further interventions are needed. This information can guide the nurse in adjusting fluid therapy and preventing complications associated with dehydration.
3.
Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium?
Correct Answer
D. 18-year-old Albert who has renal disease
Explanation
The correct answer is 18-year-old Albert who has renal disease. Renal disease affects the kidneys' ability to remove excess potassium from the body. High levels of potassium can be dangerous for individuals with renal disease as it can lead to a condition called hyperkalemia. Therefore, it is important for the nurse to discuss the importance of avoiding foods high in potassium with Albert to prevent complications associated with high potassium levels.
4.
Genevieve is diagnosed with hypomagnesemia. which nursing intervention would be appropriate?
Correct Answer
A. Instituting seizure precaution to prevent injury
Explanation
Hypomagnesemia is a condition characterized by low levels of magnesium in the blood. One of the potential complications of hypomagnesemia is seizures. Instituting seizure precautions, such as padding the bed, removing any potential hazards, and closely monitoring the client, would be an appropriate nursing intervention to prevent injury in case a seizure occurs. This intervention focuses on the specific risk associated with hypomagnesemia and aims to ensure the safety of the client.
5.
Which electrolyte would the nurse identify as the major electrolyte responsible for determining the concentration of the extracellular fluid?
Correct Answer
D. Sodium
Explanation
Sodium is the major electrolyte responsible for determining the concentration of the extracellular fluid. It plays a crucial role in maintaining fluid balance and regulating blood pressure. Sodium ions are primarily found outside the cells and help to maintain the osmotic pressure of the extracellular fluid. Any changes in sodium levels can lead to imbalances in fluid volume and affect the functioning of various body systems. Therefore, the nurse would identify sodium as the major electrolyte responsible for determining the concentration of the extracellular fluid.
6.
Jon has a potassium level of 6.5 mEq/L. which medication would nurse Wilma anticipate?
Correct Answer
B. Kayexalate
Explanation
A potassium level of 6.5 mEq/L indicates hyperkalemia, which is an elevated level of potassium in the blood. Kayexalate is a medication used to treat hyperkalemia by binding to excess potassium in the body and promoting its excretion through the gastrointestinal tract. Therefore, nurse Wilma would anticipate administering Kayexalate to help lower Jon's potassium level.
7.
Which clinical manifestation would lead the nurse to suspect that a client is experiencing hypermagnesemia?
Correct Answer
B. Hot. flushed skin and diapHoresis
Explanation
Hot, flushed skin and diaphoresis are clinical manifestations that may indicate hypermagnesemia. Hypermagnesemia is an excess of magnesium in the blood, which can cause vasodilation and increased blood flow to the skin, leading to hot and flushed skin. Diaphoresis, or excessive sweating, can also occur as the body tries to regulate its temperature. These symptoms are important to recognize as they can help the nurse identify and intervene in cases of hypermagnesemia.
8.
Lisa. a client with altered urinary function. is under the care of nurse Tine. Which intervention is appropriate to include when developing a plan of care for Lisa who is experiencing urinary dribbling?
Correct Answer
C. Keeping the skin clean and dry
Explanation
Keeping the skin clean and dry is an appropriate intervention for Lisa who is experiencing urinary dribbling. This is important because urinary dribbling can lead to skin irritation and breakdown. By keeping the skin clean and dry, the nurse can prevent complications such as infection and discomfort for the client. This intervention focuses on maintaining the client's hygiene and promoting their overall comfort and well-being.
9.
Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34. partial pressure of arterial oxygen of 80 mm Hg. partial pressure of arterial carbon dioxide of 49 mm Hg. and a bicarbonate level of 24 mEq/L. Based on these results. which intervention should the nurse implement?
Correct Answer
C. Encouraging the client to cough and deep breathe
Explanation
The given ABG values indicate that Mr. Salcedo has a pH level of 7.34, which is slightly acidic, and a partial pressure of arterial carbon dioxide of 49 mm Hg, which is higher than the normal range. These values suggest respiratory acidosis, which occurs when there is an excess of carbon dioxide in the blood. Encouraging the client to cough and deep breathe can help to increase ventilation and eliminate excess carbon dioxide, thus correcting the acidosis. Therefore, this intervention is appropriate in this situation.
10.
A client is diagnosed with metabolic acidosis. which would the nurse expect the health care provider to order?
Correct Answer
B. Sodium bicarbonate
Explanation
In cases of metabolic acidosis, there is an excess of acid in the body due to a buildup of metabolic waste products. Sodium bicarbonate is commonly used to treat metabolic acidosis as it acts as a buffer, helping to neutralize the excess acid and restore the body's pH balance. Therefore, it is expected that the healthcare provider would order sodium bicarbonate to address the client's metabolic acidosis.