Nursing Elites

1. A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results: pH 7.32, PaO2 88 mm Hg, PaCO2 37 mm Hg, and HCO3 16 mEq/L. How should the nurse interpret these results?

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

Correct answer: A

Rationale: The patient's pH is below the normal range (7.35-7.45), and the HCO3 is also below the normal range (22-26 mEq/L), indicating an acidic environment, which is consistent with metabolic acidosis. The ABGs provided do not support respiratory acidosis or alkalosis, as the PaCO2 is within the normal range (35-45 mm Hg) despite the patient's deep, rapid respirations. Therefore, the correct interpretation is metabolic acidosis.

2. An adult who has recurrent episodes of depression tells the nurse that the prescribed antidepressant needs to be discontinued because the client is feeling better after taking the medication for the past couple of weeks and does not like the side effects. Which response is best for the nurse to provide?

• A. Remind the client that feeling better is the therapeutic effect of the medication.
• B. Inform the client that gradual tapering must be used to discontinue the medication.
• C. Tell the client to discuss the medication side effects with the healthcare provider.
• D. Tell the client that the medication side effects will most likely diminish over time.

Correct answer: B

Rationale: The best response for the nurse is to inform the client that gradual tapering must be used to discontinue the medication. Abrupt cessation of antidepressants can lead to withdrawal symptoms or a recurrence of depressive symptoms. Choice A is not the best response as it does not address the need for a proper discontinuation plan. Choice C is not the best response as it focuses solely on the side effects and does not address the discontinuation process. Choice D is not the best response because while side effects may diminish over time, the focus here should be on the safe discontinuation of the medication to prevent adverse effects.

3. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?

• A. Plan low-carbohydrate and high-protein meals
• B. Engage in moderate physical activity for an hour daily
• C. Keep a record of food and drinks consumed daily
• D. Participate in a group exercise class 3 times a week

Correct answer: C

Rationale: A BMI of 30 indicates the patient is obese. The first step in a weight loss plan should be to keep a food journal to track calorie intake, which can help in meal planning and creating a workout routine. Choice (A) suggests a dietary approach, which is important but not the first step. Choice (B) recommends strenuous activity, which may not be suitable for everyone and is not the initial step. Choice (D) involves group exercise, which can be beneficial but is not the primary action to take at the beginning of a weight loss plan.

4. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

• A. Ask the wife how she would like to participate in the client's care
• B. Provide the wife with information about hospice
• C. Encourage the wife to visit after painful treatments are completed
• D. Refer the wife to a support group for family members of those dying of cancer

Correct answer: A

Rationale: The most beneficial nursing intervention in this situation is to ask the wife how she would like to participate in the client's care. Involving the spouse in the care of the terminally ill client can provide comfort, support, and a sense of contribution during a challenging time. Providing information about hospice (B) is important but may not be the immediate priority. Encouraging the wife to visit after treatments are completed (C) may delay her involvement in the care. Referring her to a support group (D) is a good idea but might be more suitable at a later stage.

5. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? (Select all that apply).

• A. Tops of the ears
• B. Bridge of the nose
• C. Around the nostrils
• D. Over the cheeks

Correct answer: C

Rationale: The correct answer is C: 'Around the nostrils.' Constant pressure from the tubing may create skin damage to the areas of skin and bony prominences the nasal cannula will be resting on, including around the nostrils. Choice A, 'Tops of the ears,' is incorrect as the cannula does not rest on the ears. Choice B, 'Bridge of the nose,' is incorrect because the cannula typically rests under the nose. Choice D, 'Over the cheeks,' is also incorrect as the cannula does not typically rest on the cheeks.

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