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Questions 164

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Question 1 of 5

The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis?

Correct Answer: A

Rationale: Severe diarrhea is the only problem listed that can lead to metabolic acidosis if untreated.

Question 2 of 5

A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is

Correct Answer: D

Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.

Question 3 of 5

A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment?

Correct Answer: D

Rationale: A decreasing WBC count indicates resolving infection, as HAP elevates WBCs. Sputum color is unreliable, lung sounds improve later, and oxygen saturation reflects oxygenation, not infection status.

Question 4 of 5

A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110 BPM, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?

Correct Answer: B

Rationale: Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for decreased oxygenation is increased respiratory rate.

Question 5 of 5

The nurse is collecting data from a client who had a cesarean birth 12 hours ago. The client is restless, has a heart rate of 115/min, and is reporting dyspnea and anxiety. It would be a priority for the nurse to

Correct Answer: A

Rationale: Restlessness, tachycardia, dyspnea, and anxiety post-cesarean suggest pulmonary embolism, a common postpartum complication. Pulse oximetry assesses oxygenation urgently. Pain, DVT, or anxiety are less immediate concerns.

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