Questions 151

NCLEX-RN

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Question 1 of 5

A client complains of a dull headache and dizziness and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH 7.26; partial pressure of carbon dioxide,50 mm Hg; and bicarbonate, 24 mEq/L. These findings indicate which of the following acid-base imbalances?

Correct Answer: B

Rationale: A pH of 7.26 (acidic) with elevated CO2 (50 mm Hg) and normal bicarbonate (24 mEq/L) indicates respiratory acidosis, likely due to hypoventilation. Other imbalances do not match these values.

Question 2 of 5

You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:

Correct Answer: C

Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.

Question 3 of 5

The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal?

Correct Answer: C

Rationale: Prophylactic antacids or H2 receptor antagonists reduce gastric acid, preventing stress ulcers in burn patients, who are at high risk due to stress response.

Question 4 of 5

The nurse is assessing a client with suspected appendicitis. Which of the following findings would support this diagnosis?

Correct Answer: A, B

Rationale: Pain at McBurney's point and decreased bowel sounds are classic signs of appendicitis due to peritoneal irritation and intestinal obstruction.

Question 5 of 5

The nurse is caring for a client with a new diagnosis of glaucoma. Which medication class should the nurse expect to administer?

Correct Answer: A

Rationale: Beta-blockers, such as timolol, reduce intraocular pressure in glaucoma by decreasing aqueous humor production, the primary treatment goal.

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