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A nurse is caring for a client who is acidotic. The nurse asks the charge
nurse why the client is breathing rapidly. What response by
the charge nurse is best?
a. Anxiety is causing the client to breathe rapidly.
b. The client is trying to get rid of excess body acids.
c. The rapid respirations cause buildup of bicarbonate.
d. An increased respiratory rate is due to increased metabolism. -
ANSWER ✔✔ANS: B
,The client is acidotic, and the respiratory system is attempting to
compensate by "blowing off" excess acid in the form of carbon
dioxide. The increased respiratory rate is not due to anxiety or increased
metabolism. An increased respiratory rate does not cause a
buildup of bicarbonate.
A client had a recent thromboembolism and must resume work which
requires frequent car and plane travel. What self-care
measure does the nurse teach to reduce the risk of impaired clotting in
this client?
a. Get up and walk around at least every 2 hours while traveling.
b. Use a soft toothbrush and an electric razor for safety.
c. Be sure to sit with the legs elevated as much as possible.
d. Increase fiber in the diet so as not to strain to move the bowels. -
ANSWER ✔✔ANS: A
,Clients who are at risk of increased clotting (as evidenced by prior
thromboembolic event) can take several measures to reduce their risk of
further problems. One measure is to get up and walk frequently when
sitting for a long period of time. Using a soft toothbrush and an electric
razor and needing to prevent constipation would be important for a client
at risk of bleeding. Elevating the legs is not as beneficial as ambulating.
A nurse is caring for four clients. Which client does the nurse assess first
for impaired cognition?
a. A 28-year-old client 2 days post-open cholecystectomy
b. An 88-year-old client 3 days post-hemorrhagic stroke
c. A 32-year-old client with a 20-pack-year history of smoking
d. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L) -
ANSWER ✔✔ANS: B
There are many risk factors for impaired cognition including advanced
age and diseases and disorders that affect the brain. The
88-year-old client who is recovering from a stroke has two such risk
factors and is at highest risk for impaired cognition. The nurse
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, assesses this client first. The other clients have a much lower risk of
developing impaired cognition.
The assistive personnel (AP) reports to the registered nurse that a
postoperative client has a pulse of 132 beats/min and a blood
pressure of 168/90 mm Hg. What response by the nurse is most
appropriate?
a. Ask the AP to repeat the client's vital signs in 15 minutes.
b. Assess the client for pain.
c. Ask the client if something is bothersome.
d. Instruct the AP to reposition the client - ANSWER ✔✔ANS: B
The "fight-or-flight" syndrome can occur from sympathetic nervous
stimulation due to acute pain. Symptoms can include nausea, vomiting,
diaphoresis, tachycardia, tachypnea, hypertension, and dilated pupils.
Since this client is postoperative, it is reasonable to believe that he or
she might be in pain. The nurse first assesses for pain or discomfort and
treats it. If the client is not in pain, the nurse would conduct further
assessments to determine the cause of the abnormal vital signs.