Nursing Elites

1. A client has the following arterial blood gas (ABG) results: pH 7.51, PCO2 31 mm Hg, PO2 94 mm Hg, HCO3 24 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results?

• A. Metabolic acidosis
• B. Metabolic alkalosis
• C. Respiratory acidosis
• D. Respiratory alkalosis

Correct answer: D

Rationale: The ABG results show a pH above the normal range (7.35-7.45) and a decreased PCO2, indicating respiratory alkalosis. In respiratory alkalosis, the pH is increased and the PCO2 is decreased. Metabolic acidosis (choice A) would present with a low pH and low HCO3 levels. Metabolic alkalosis (choice B) would show an increased pH and HCO3 levels. Respiratory acidosis (choice C) would have a low pH and an increased PCO2.

2. A patient’s serum osmolality is 305 mOsm/kg. Which term describes this patient’s body fluid osmolality?

• A. Iso-osmolar
• B. Hypo-osmolar
• C. Hyperosmolar
• D. Isotonic

Correct answer: C

Rationale: The correct term to describe a patient with a serum osmolality of 305 mOsm/kg is 'hyperosmolar.' Normal osmolality ranges from 280 to 300 mOsm/kg. A patient with an osmolality above this range is considered hyperosmolar. Choice A ('Iso-osmolar') implies an equal osmolality, which is not the case in this scenario. Choice B ('Hypo-osmolar') suggests a lower osmolality, which is incorrect based on the provided serum osmolality value. Choice D ('Isotonic') refers to a solution having the same osmolality as another solution, not describing the specific scenario of this patient being above the normal range.

3. The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

• A. Presence and activity of bowel sounds
• B. Color and consistency of feces
• C. Eating patterns and dietary intake
• D. Level and amount of physical activity

Correct answer: C

Rationale: In chronic pancreatitis, managing abdominal pain is crucial, and assessing the client's eating patterns and dietary intake is essential. Dietary modifications can help alleviate symptoms and reduce the workload on the pancreas. Choices A, B, and D are not directly related to pain management in chronic pancreatitis. Bowel sounds, fecal characteristics, and physical activity may provide important information in other conditions but are not the priority in this scenario.

4. A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client?

• A. Assessing the client’s chest for crepitus every 24 hours
• B. Taping the connections between the chest tube and the drainage system
• C. Adding 20 mL of sterile water to the suction control chamber every shift
• D. Recording the volume of secretions in the drainage collection chamber every 24 hours

Correct answer: B

Rationale: The correct action for the nurse to take in caring for a client with a chest tube connected to a closed chest drainage system is to tape the connections between the chest tube and the drainage system. This is done to prevent accidental disconnection, ensuring the system functions properly. Assessing the client’s chest for crepitus should be done more frequently than once every 24 hours to monitor for any air leaks. Adding sterile water to the suction control chamber is not necessary every shift; it should be done as needed to maintain the appropriate water level. Recording the volume of secretions in the drainage collection chamber should be done more frequently than every 24 hours, with hourly monitoring during the first 24 hours after insertion and every 8 hours thereafter to assess for changes or complications.

5. The nurse is preparing to administer the first dose of an antibiotic to a patient admitted for a urinary tract infection. Which action is most important prior to administering the antibiotic?

• A. Administering a small test dose to determine if hypersensitivity exists
• B. Having epinephrine available in case of a severe hypersensitivity reaction
• C. Monitoring baseline vital signs, including temperature and blood pressure
• D. Obtaining a specimen for culture and sensitivity

Correct answer: D

Rationale: The most crucial action before administering an antibiotic for a urinary tract infection is to obtain a specimen for culture and sensitivity. This ensures the accurate identification of the causative organism and helps determine the most effective antibiotic therapy. Administering a test dose to detect hypersensitivity is usually reserved for cases with a strong suspicion of allergy to a needed antibiotic. Keeping epinephrine available is important when there is a significant risk of a severe allergic reaction. Monitoring baseline vital signs is essential during antibiotic therapy but is not the top priority before administering the first dose.

Similar Questions