HESI Comprehensive A Review for the NCLEX-RN® Examination, 7th Edition TESTBANK 2024

1.Six hours following thoracic surgery, a client has the following arterial blood gas (ABG) findings: pH, 7.50; PaCO2, 30 mm Hg; HCO3, 25 mEq/L; PaO2, 96 mm Hg. What is the best nursing action based on these results? Correct Answer A Increase the oxygen flow rate from 4 to 10 L/min per nasal cannula. B Assess the client for pain and administer pain medication as prescribed. C Encourage the client to take short shallow breaths for 5 minutes. D Prepare to administer sodium bicarbonate IV over 30 minutes. Rationale: These ABGs reveal respiratory alkalosis, and treatment depends on the underlying cause. Because the client is only 6 hours postoperative, he or she should be assessed for pain because treating the pain will correct the underlying problem. A PaO2 of 96 mm Hg does not indicate the need for an increase in oxygen administration. The PaCO2 indicates mild hyperventilation, so option C is not indicated. In addition, it is very difficult to change one’s breathing pattern. The use of sodium bicarbonate is indicated for the treatment of metabolic acidosis, not respiratory alkalosis. 2.Which assessment finding for a client with peritoneal dialysis requires an immediate action by the nurse? Correct Answer A The color of the dialysate outflow is opaque yellow. B The dialysate outflow is greater than the inflow. C The inflow dialysate feels warm to the touch. D The inflow dialysate contains potassium chloride. Rationale: Opaque or c