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Questions 148

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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 and PCO2 of 28 indicate respiratory alkalosis, likely due to hyperventilation from the head injury.

Question 2 of 5

The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:

Correct Answer: B

Rationale: A pain scale provides a reliable, subjective measure of pain.

Question 3 of 5

Which of the following tasks are appropriate for the nurse to delegate to unlicensed assistive personnel? Select all that apply.

Correct Answer: B,C,E

Rationale: Unlicensed assistive personnel can perform routine tasks like checking routine vital signs (
B), measuring urinary output (
C), and assisting with ambulation (E). Checking vital signs in an acutely ill client (
A) and monitoring a transfusion (
D) require a nurse's assessment skills.

Question 4 of 5

The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:

Correct Answer: C

Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.

Question 5 of 5

A child with Down syndrome has a developmental age of 4 years. According to the Denver Developmental Assessment, the 4-year-old should be able to:

Correct Answer: B

Rationale: Per the Denver Developmental Screening Test, a 4-year-old should be able to give their first and last name, a milestone achievable despite developmental delays.

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