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Questions & Detailed Answer Rationales from Top
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A nurse reviews arterial blood gas (ABG) values and notes a pH of 7.50 and a Pco2 of 30
mm Hg. What does the nurse interpret these values as indicative of?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis - CORRECT ANS- -Respiratory alkalosis
Rationale: The nurse interprets these values as indicative of respiratory alkalosis. The
normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory alkalosis, the
pH will be higher than normal and the Pco2 will be low.
A nurse provides information to a client with chronic obstructive pulmonary disease
(COPD) about methods of alleviating shortness of breath while the client is eating. Which
statement by the client indicates a need for further instruction?
"I should rest before I eat."
"I should use my bronchodilator 30 minutes before I eat."
"Pursed-lip breathing will help relieve my shortness of breath."
"I should eat three meals a day, and the biggest meal should be at suppertime." - CORRECT
ANS- -"I should eat three meals a day, and the biggest meal should be at suppertime."
Rationale: There is a need for further instruction if the client states, "I should eat three
meals a day, and the biggest meal should be at suppertime." The biggest meal of the day is
planned for the time when the client is hungriest and most rested. Most clients are
,increasingly tired at the end of the day. Four to six small meals per day are preferable to
three larger ones. Pursed-lip or abdominal breathing may alleviate dyspnea.Shortness of
breath is the most common problem related to eating for a client with COPD. The client can
ease dyspnea by resting before meals. A bronchodilator used 30 minutes before a meal
may be helpful if the meal-related dyspnea is a result of bronchospasm or secretions.
A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For
which characteristic sign/symptom of this complication does the nurse monitor the client?
Pleuritic chest pain
Slowed heart rate
Chills and a high fever
Decreased respiratory rate - CORRECT ANS- -Pleuritic chest pain
Rationale: The characteristic signs/symptoms of pulmonary embolism are dyspnea,
tachypnea, tachycardia, and pleuritic chest pain (sharp, stabbing pain on inspiration).
Pulmonary embolism, whch results in blockage of the main artery of the lung or one of its
branches, occurs when an object, such as a clot, or substance travels from elsewhere in
the body through the bloodstream (embolism). The client may become apprehensive and
restless. A low-grade fever may occur. Chills and a high fever are characteristics of an
infection.
A nurse caring for a client 24 hours after a radical neck dissection notes the presence of
serosanguineous drainage in the portable wound suction device attached to the surgical
site. On the basis of this finding, what should the nurse do?
Document the findings
Contact the primary health care provider
Ask the primary health care provider to remove the drains
, Increase the pressure on the wound suction device - CORRECT ANS- -Document the
findings
Rationale: Because the findings detailed in the question are expected, the nurse would
document them. Immediately after radical neck dissection, the client will have a wound
drain in the neck, attached to portable suction. The nurse places the client in the semi-
Fowler position to minimize postoperative edema and monitors the neck drainage for
volume and color. Sanguineous and serosanguineous drainage is expected in the 72 hours
after surgery. Once drainage has stopped, the wound drains are removed.
Although previously well controlled with glyburide, a client's fasting blood glucose has
been running 180 to 200 mg/dL (10 to 11.1 mmol/L). On reviewing the client's record, which
medication, recently added to the client's regimen, does the nurse recognize as a possible
contributor to the hyperglycemia?
Atenolol
Phenelzine
Allopurinol
Lithium carbonate - CORRECT ANS- -Lithium carbonate
Rationale: Glyburide is a hypoglycemic medication. If the client takes a corticosteroid,
thiazide diuretic, or lithium carbonate concurrently, the effect of the glyburide is
diminished. Lithium carbonate, an antimanic medication, may increase the blood glucose
level. Phenelzine is a monoamine oxidase inhibitor. Atenolol is a beta-blocker. Allopurinol
is a xanthine oxidase inhibitor. These medications may amplify the effects of an oral
hypoglycemic.
A nurse is performing an assessment of a client with suspected pheochromocytoma.
Which clinical manifestation does the nurse expect to note?
Weight gain
Questions & Detailed Answer Rationales from Top
Global Institutions for Guaranteed Achievement
A nurse reviews arterial blood gas (ABG) values and notes a pH of 7.50 and a Pco2 of 30
mm Hg. What does the nurse interpret these values as indicative of?
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Respiratory alkalosis - CORRECT ANS- -Respiratory alkalosis
Rationale: The nurse interprets these values as indicative of respiratory alkalosis. The
normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory alkalosis, the
pH will be higher than normal and the Pco2 will be low.
A nurse provides information to a client with chronic obstructive pulmonary disease
(COPD) about methods of alleviating shortness of breath while the client is eating. Which
statement by the client indicates a need for further instruction?
"I should rest before I eat."
"I should use my bronchodilator 30 minutes before I eat."
"Pursed-lip breathing will help relieve my shortness of breath."
"I should eat three meals a day, and the biggest meal should be at suppertime." - CORRECT
ANS- -"I should eat three meals a day, and the biggest meal should be at suppertime."
Rationale: There is a need for further instruction if the client states, "I should eat three
meals a day, and the biggest meal should be at suppertime." The biggest meal of the day is
planned for the time when the client is hungriest and most rested. Most clients are
,increasingly tired at the end of the day. Four to six small meals per day are preferable to
three larger ones. Pursed-lip or abdominal breathing may alleviate dyspnea.Shortness of
breath is the most common problem related to eating for a client with COPD. The client can
ease dyspnea by resting before meals. A bronchodilator used 30 minutes before a meal
may be helpful if the meal-related dyspnea is a result of bronchospasm or secretions.
A postoperative client with deep-vein thrombosis is at risk for pulmonary embolism. For
which characteristic sign/symptom of this complication does the nurse monitor the client?
Pleuritic chest pain
Slowed heart rate
Chills and a high fever
Decreased respiratory rate - CORRECT ANS- -Pleuritic chest pain
Rationale: The characteristic signs/symptoms of pulmonary embolism are dyspnea,
tachypnea, tachycardia, and pleuritic chest pain (sharp, stabbing pain on inspiration).
Pulmonary embolism, whch results in blockage of the main artery of the lung or one of its
branches, occurs when an object, such as a clot, or substance travels from elsewhere in
the body through the bloodstream (embolism). The client may become apprehensive and
restless. A low-grade fever may occur. Chills and a high fever are characteristics of an
infection.
A nurse caring for a client 24 hours after a radical neck dissection notes the presence of
serosanguineous drainage in the portable wound suction device attached to the surgical
site. On the basis of this finding, what should the nurse do?
Document the findings
Contact the primary health care provider
Ask the primary health care provider to remove the drains
, Increase the pressure on the wound suction device - CORRECT ANS- -Document the
findings
Rationale: Because the findings detailed in the question are expected, the nurse would
document them. Immediately after radical neck dissection, the client will have a wound
drain in the neck, attached to portable suction. The nurse places the client in the semi-
Fowler position to minimize postoperative edema and monitors the neck drainage for
volume and color. Sanguineous and serosanguineous drainage is expected in the 72 hours
after surgery. Once drainage has stopped, the wound drains are removed.
Although previously well controlled with glyburide, a client's fasting blood glucose has
been running 180 to 200 mg/dL (10 to 11.1 mmol/L). On reviewing the client's record, which
medication, recently added to the client's regimen, does the nurse recognize as a possible
contributor to the hyperglycemia?
Atenolol
Phenelzine
Allopurinol
Lithium carbonate - CORRECT ANS- -Lithium carbonate
Rationale: Glyburide is a hypoglycemic medication. If the client takes a corticosteroid,
thiazide diuretic, or lithium carbonate concurrently, the effect of the glyburide is
diminished. Lithium carbonate, an antimanic medication, may increase the blood glucose
level. Phenelzine is a monoamine oxidase inhibitor. Atenolol is a beta-blocker. Allopurinol
is a xanthine oxidase inhibitor. These medications may amplify the effects of an oral
hypoglycemic.
A nurse is performing an assessment of a client with suspected pheochromocytoma.
Which clinical manifestation does the nurse expect to note?
Weight gain
