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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 nurse is evaluating nutritional outcomes for a client with anorexia nervosa. Which one of the following is the most objective favorable outcome for the client?

Correct Answer: C

Rationale: Weight gain is the most objective and measurable outcome for anorexia nervosa, indicating improved nutritional status and progress toward recovery.

Question 3 of 5

An infant with a ventricular septal defect is discharged with a prescription for lanoxin elixir 0.01 mg PO q 12 hrs. The bottle is labeled 0.10 mg per 1/2 tsp. The nurse should instruct the mother to:

Correct Answer: B

Rationale: The calibrated dropper ensures accurate dosing of Lanoxin (digoxin), critical for preventing toxicity in infants.

Question 4 of 5

The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:

Correct Answer: B

Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.

Question 5 of 5

What is the critical point for PO2 (the 'ICU' point), the percentage point at which there is marked decrease in oxygen saturation? Record your answer using a whole number.

Correct Answer: 90

Rationale: The critical PO2 point is around 90 mmHg, where oxygen saturation drops significantly, often requiring ICU intervention.

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The nurse is caring for a client who is receiving a blood transfusion. Fifteen minutes after the transfusion begins, the client reports itching and develops hives. Which of the following actions should the nurse take FIRST?

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