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Questions 158

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Extract:


Question 1 of 5

Which of the following blood gas parameters primarily reflects respiratory function?

Correct Answer: A

Rationale: The lungs are responsible for regulation of CO2, and this parameter primarily reflects respiratory function.

Question 2 of 5

The nurse receives report on the group of clients listed here. Place the client list in sequential priority order for the nurse to assess. (Most important for the nurse to assess first, second, third, and fourth.)

Order the Items

Source Container

Client admitted from the emergency room previous shift with unrelieved migraine headache.
Client transferred from surgical intensive care after traumatic brain injury. Pulse oximetry reading 94%.
Client with a Glasgow coma scale (GCS) of 5 with evidence of cerebral aneurysm rupture on CT scan.
Client admitted from the emergency room after a motor vehicle accident and GCS of 13

Correct Answer: C, B, D, A

Rationale: Priority: GCS 5 with aneurysm (
C) is life-threatening, followed by traumatic brain injury (B, potential deterioration), motor vehicle accident with GCS 13 (D, stable but needs monitoring), and migraine (A, non-emergent).

Question 3 of 5

Which of the following findings would be expected in the infant with biliary atresia?

Correct Answer: C

Rationale: Biliary atresia causes bile flow obstruction, leading to abdominal distention (from hepatomegaly) and poor weight gain due to malabsorption. Stools are pale, not dark, and weight gain is not rapid.

Question 4 of 5

While reading the progress notes on a client with cancer, the nurse notes a TNM classification of T1, N1, M0. What does this classification indicate?

Correct Answer: D

Rationale: T1 indicates a small tumor, N1 indicates regional lymph node involvement, and M0 indicates no distant metastasis. Option A is incorrect (T1 is not in situ), B is incorrect (T0, not T1, means no tumor), and C is incorrect (M0 means no metastasis).

Question 5 of 5

The nurse is caring for a client with a history of a myocardial infarction. The client is receiving TPA (alteplase). The nurse should monitor the client for:

Correct Answer: A

Rationale: TPA, a thrombolytic, increases bleeding risk by dissolving clots. Monitoring for bleeding (e.g., gums, urine) is critical. Hypertension, hypoglycemia, and hyperthermia are not primary concerns.

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