Nursing Elites

1. A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results?

• A. Diarrhea and vomiting for 36 hours
• B. . Anxiety-induced hyperventilation
• C. Chronic obstructive pulmonary disease (COPD)
• D. Diabetic ketoacidosis and emphysema

Correct answer: B

Rationale:

2. The chief mechanism for maintaining fluid balance is to:

• A. adjust fluid intake so it equals fluid output.
• B. adjust fluid intake so it is slightly above fluid output.
• C. adjust fluid output so it equals fluid input.
• D. adjust fluid intake so it is slightly below fluid output.

Correct answer: C

Rationale: The correct answer is C: 'adjust fluid output so it equals fluid input.' Maintaining fluid balance involves ensuring that the amount of fluid lost through processes like urination, sweating, and respiration equals the amount of fluid taken in. This ensures that the body stays properly hydrated. Choices A, B, and D are incorrect because they do not focus on the balance between fluid input and output, which is crucial for maintaining proper fluid balance. By adjusting fluid output to equal fluid input, the body can regulate hydration levels effectively, preventing dehydration or overhydration.

3. A nurse assesses a client who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next?

• A. Assess clients rate, rhythm, and depth of respiration.
• B. Measure the clients pulse and blood pressure.
• C. Document the findings and continue to monitor.
• D. Notify the physician as soon as possible.

Correct answer: A

Rationale:

4. You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patient's plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to assess what aspect of the patient's health?

• A. Nutritional status
• B. Potassium balance
• C. Calcium balance
• D. Fluid volume status

Correct answer: D

Rationale: Assessing the specific gravity in a patient with SIADH helps the nurse evaluate the patient's fluid volume status. Specific gravity indicates the concentration of solutes in the urine and can detect if the patient has a fluid volume deficit or excess. Nutritional status, potassium balance, and calcium balance are not directly assessed through specific gravity testing. Nutritional status is typically evaluated through dietary intake and anthropometric measurements. Potassium balance is assessed through blood tests and ECG monitoring. Calcium balance is evaluated through blood tests and bone density scans. Therefore, the correct answer is assessing fluid volume status through specific gravity testing.

5. Extracellular fluid includes:

• A. plasma and intracellular fluid.
• B. interstitial and intracellular fluids.
• C. plasma and interstitial fluid.
• D. plasma, interstitial fluid, and intracellular fluid.

Correct answer: C

Rationale: The correct answer is C: 'plasma and interstitial fluid.' Extracellular fluid consists of all body fluids outside the cells, primarily including plasma (the liquid component of blood) and interstitial fluid (the fluid between cells). Choices A, B, and D are incorrect because intracellular fluid is located within the cells, not in the extracellular fluid compartment.

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