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Questions 148

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Question 1 of 5

A client has experienced 48 hours of severe repeated bouts of vomiting. Which acid-base imbalance is of most concern?

Correct Answer: D

Rationale: Severe vomiting causes loss of gastric acid, leading to metabolic alkalosis (
D). Respiratory imbalances (A,
B) and metabolic acidosis (
C) are less likely.

Question 2 of 5

The charge nurse in a cardiac ICU is precepting a student nurse. Which action by the student nurse requires immediate intervention by the charge nurse?

Correct Answer: B

Rationale: Lifting the urinary catheter bag above the bladder risks backflow of urine, increasing infection risk, and requires immediate intervention.

Question 3 of 5

Following procurement of organs from a standard criteria donor (donor younger than 50 years who suffered brain death), within what time period should the heart and lungs be transplanted?

Correct Answer: A

Rationale: Heart and lungs have a short ischemic tolerance, requiring transplantation within 4-6 hours (
A) to ensure viability. Longer periods (B, C,
D) risk organ failure.

Question 4 of 5

A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100 mL. The nurse should:

Correct Answer: A

Rationale: The parameters (BP 160/80, 1+ reflexes, 100 mL urine output) are within acceptable limits, so the infusion should continue.

Question 5 of 5

The nurse is assessing a client with suspected pneumothorax. Which of the following findings would the nurse expect?

Correct Answer: B

Rationale: decreased breath sounds on the affected side are a hallmark of pneumothorax due to lung collapse

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