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Questions 158

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Question 1 of 5

The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings indicate that the client has:

Correct Answer: B

Rationale: A pH of 7.47 (alkaline) with low PCO2 (28) indicates respiratory alkalosis, likely from hyperventilation due to brain injury. Normal HCO3 rules out metabolic causes.

Question 2 of 5

A premature infant needs supplemental O2 therapy. A nursing intervention that reduces the risk of retrolental fibroplasia is to:

Correct Answer: A

Rationale: Maintaining O2 at <40% minimizes the risk of retrolental fibroplasia, a complication of high oxygen levels in premature infants.

Question 3 of 5

A client with a history of hypertension is receiving Aldactone (spironolactone). The nurse should teach the client to avoid:

Correct Answer: A

Rationale: Spironolactone is a potassium-sparing diuretic, and consuming potassium-rich foods can lead to hyperkalemia. Calcium, fiber, and iron supplements are not contraindicated.

Question 4 of 5

The nurse is caring for a client with a history of a fractured humerus who is in a sling. The client complains of numbness. The nurse should:

Correct Answer: C

Rationale: Numbness in a slung humerus suggests neurovascular compromise, requiring immediate physician notification. Ice, elevation, and massage are insufficient or contraindicated.

Question 5 of 5

A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?

Correct Answer: C

Rationale: Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous.

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