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Questions 158

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Question 1 of 5

A 52-year-old female client is admitted to the hospital in acute renal failure. She has been on hemodialysis for the past 2 years. Stat arterial blood gases are drawn on the client yielding the following results: pH 7.30, PCO2 51 mm Hg, HCO3 18 mEq/L, PaO2 84 mm Hg. The nurse would interpret these results as:

Correct Answer: D

Rationale: Compensated metabolic alkalosis would be reflected by the following: pH within normal limit (7.35-7.45), PCO2 >45 mm Hg, HCO3 >26 mEq/L. Respiratory acidosis would be reflected by the following: pH <7.35, PCO2 >45 mm Hg, HCO3 within normal limits (22-26 mEq/L). Partially compensated metabolic alkalosis would be reflected by the following: pH >7.45, PCO2 >45 mm Hg, HCO3 >26 mEq/L. Combined respiratory and metabolic acidosis would be reflected by the following: pH <7.35, PCO2 >45 mm Hg, HCO3 <22 mEq/L.

Question 2 of 5

The physician has ordered atropine sulfate 0.4 milligrams IM before surgery. The medication is supplied in 0.8 milligrams per milliliter. How much medication should the nurse prepare to administer?

Correct Answer: 0.5

Rationale:
To calculate: 0.4 mg desired ÷ 0.8 mg/mL = 0.5 mL. The nurse should prepare 0.5 mL of atropine sulfate.

Question 3 of 5

A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:

Correct Answer: B

Rationale: Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. FHR (movement) observed DISTINCT on ultrasound is a positive diagnosis of pregnancy. Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.

Question 4 of 5

A client has chronic obstructive pulmonary disease. She is slowly losing weight, and her daughter is very concerned about increasing her nutrition. The nurse helps the daughter devise a plan of care for her mother. The plan of care should include which of the following interventions to promote nutrition?

Correct Answer: A

Rationale: Clients with respiratory diseases are generally mouth breathers. Cleaning the oral cavity may improve the client's appetite, increase her feelings of well-being, and remove the taste and odor of sputum. Milk causes thick sputum; therefore, milk products would not be beneficial for this client. Exercise prior to a meal would require increased O2 consumption and most likely would decrease the client's ability to eat. Clients with respiratory diseases need increased fluid to liquefy secretions.

Question 5 of 5

A client is scheduled for a magnetic resonance imaging (MRI) to locate a cerebral lesion. It is important for the nurse to find out if he has a(n):

Correct Answer: C

Rationale: Iodine is not used as a contrast medium for MRI. It is important to inquire about allergy to seafood if the client is to have an arteriogram or enhanced computer tomography. MRI is safe if seizures are under control. It is more important to inquire about movable metal implants. Clients with movable metal implants such as shrapnel or aneurysm clips or clients with permanent pacemakers or implanted pumps can be traumatized during an MRI. Nonmovable metal prostheses or hardware will not cause trauma during an MRI.

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