the laboratory has just called with the arterial blood gas abg results on four patients which result is most important for the nurse to report immedia
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Prioritization Questions

1. The laboratory has just called with the arterial blood gas (ABG) results on four patients. Which result is most important for the nurse to report immediately to the health care provider?

Correct answer: D

Rationale: The correct answer is D: pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%. These ABG results indicate uncompensated respiratory acidosis, a critical condition that requires immediate attention. In respiratory acidosis, there is an excess of carbon dioxide in the blood, leading to a decrease in pH. The other options present normal or near-normal ABG values, indicating adequate oxygenation and ventilation. Therefore, these values would not be as urgent to report compared to the patient with respiratory acidosis in option D.

2. The nurse is working in a support group for clients with HIV. Which point is most important for the nurse to stress?

Correct answer: B

Rationale: The correct answer is that clients with HIV must take their medications exactly as prescribed. Antiretrovirals need to be taken as directed to prevent the development of drug-resistant strains and maintain treatment effectiveness. Missing doses can compromise the effectiveness of future treatments. Choice A, informing household members, is important for social support but not the most critical aspect of managing the condition. Choice C, abstaining from substance use, is important but not as crucial as medication adherence. Choice D, avoiding large crowds, is not directly related to HIV management as long as the individual's immune system is not significantly compromised.

3. A nurse and client are discussing the client's progress toward understanding his behavior under stress. This is typical of which phase in the therapeutic relationship?

Correct answer: C

Rationale: The correct answer is the working phase. During this phase, the nurse and client actively work together to explore alternative behaviors and techniques. Discussions in this phase focus on understanding the underlying meaning behind the behavior and implementing strategies for change. Pre-interaction (choice A) refers to the phase before the nurse and client first meet and establish a relationship. The orientation phase (choice B) involves introductions, setting goals, and establishing boundaries. Termination (choice D) is the phase where the therapeutic relationship concludes, and closure is achieved.

4. A nursing student caring for a 6-month-old infant is asked to collect a sample for urinalysis from the infant. How should the student collect the specimen?

Correct answer: B

Rationale: The correct method for collecting a urine sample from an infant for urinalysis is by attaching a urinary collection device to the infant's perineum. This device is a plastic bag with an adhesive opening that allows it to be secured to the perineum to collect urine. Catheterizing the infant with a Foley catheter should not be done unless specifically prescribed due to the risk of infection. Obtaining the specimen from the diaper by squeezing it after the infant voids may not provide an accurate sample for urinalysis. Trying to predict the time of the next voiding to prepare a specimen cup is not practical or reliable in ensuring an appropriate sample for urinalysis.

5. The nurse is caring for a 10-year-old on admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is:

Correct answer: A

Rationale: For a child of this age, this is adequate output, yet does not suggest overload. Disruption of sodium-ATPase activity presumably causes an intracellular sodium shift which contributes to hypovolemia and cellular edema. Heat injury also initiates the release of inflammatory and vasoactive mediators. These mediators are responsible for local vasoconstriction, systemic vasodilation, and increased transcapillary permeability. Increase in transcapillary permeability results in a rapid transfer of water, inorganic solutes, and plasma proteins between the intravascular and interstitial spaces.

Similar Questions

The nurse provides discharge instructions to a patient who was hospitalized for pneumonia. Which statement, if made by the patient, indicates a good understanding of the instructions?
A 1-year-old child is diagnosed with intussusception, and the mother of the child asks the student nurse to describe the disorder. Which statement by the student nurse indicates correct understanding of this disorder?
A child is diagnosed with a Greenstick Fracture. Which of the following most accurately describes the broken bone?
Which action will be included in the care for a patient who has recently been diagnosed with asymptomatic nonalcoholic fatty liver disease (NAFLD)?
For a 6-year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses