A nurse is caring for a client who has just experienced a 90-second tonic-clonic seizure. The clients arterial blood gas values are pH 6.88, PaO2 50 mm Hg, PaCO2 60 mm Hg, and HCO3 22 mEq/L. Which action should the nurse take first?

Correct Answer: A

Rationale: The correct answer is A: Apply oxygen by mask or nasal cannula. The client is experiencing respiratory acidosis due to inadequate ventilation and oxygenation during the seizure. Providing oxygen will help improve oxygenation and correct the respiratory acidosis. This is the priority to address the immediate physiological need. Choice B is incorrect as applying a paper bag can lead to rebreathing of carbon dioxide, worsening the respiratory acidosis. Choice C is incorrect as sodium bicarbonate is not indicated in this situation and can potentially worsen the acid-base imbalance. Choice D is incorrect as administering glucose and insulin is not relevant to correcting the respiratory acidosis.

Correct Answer: A

Rationale: The correct answer is A: Client with pancreatitis who has continuous nasogastric suctioning. Pancreatitis can lead to gastrointestinal losses of potassium, and continuous nasogastric suctioning can further exacerbate this potassium loss, putting the client at risk for hypokalemia. The other choices are incorrect because: B: ACE inhibitors can cause hyperkalemia, not hypokalemia. C: Blood transfusions can lead to hyperkalemia due to the potassium content in blood products. D: Uncontrolled diabetes and a serum pH level of 7.33 are not directly associated with hypokalemia.

Correct Answer: A

Rationale: The correct action for the nurse to take first is to assess the client's respiratory rate, rhythm, and depth (Choice A). Diminished handgrip strength in a client with hypokalemia could indicate potential respiratory muscle weakness, which can lead to respiratory distress or failure. By assessing the client's respiratory status, the nurse can determine if immediate intervention is needed to support breathing. Choice B is incorrect because measuring the client's pulse and blood pressure may not address the underlying issue of respiratory muscle weakness. Choice C is incorrect as it delays potential life-saving interventions by simply documenting findings. Choice D is incorrect as calling the healthcare provider should come after addressing the client's immediate respiratory needs.

Correct Answer: B

Rationale: The correct answer is B: Malnourished patients receiving parenteral nutrition are at risk for hypophosphatemia if calories are started too aggressively. Patient with pancreatitis may have depleted levels of phosphorus due to malnutrition, and rapid initiation of TPN can further decrease phosphorus levels, leading to hypophosphatemia. This can result in respiratory failure, muscle weakness, and arrhythmias. Choice A is incorrect because patients receiving TPN are not specifically at risk for hypercalcemia due to rapid initiation of calories. Choice C is incorrect because rapid fluid infusion can lead to hypernatremia, not related to TPN initiation. Choice D is incorrect because the rationale provided for slow initiation is not related to digestive enzymes but rather to prevent hypophosphatemia in malnourished patients.

Correct Answer: A

Rationale: The correct answer is A: Diabetic ketoacidosis in a person with emphysema. The arterial blood values show a low pH (acidosis), high PaCO2 (respiratory acidosis), and normal HCO3 (compensatory metabolic alkalosis). This pattern is consistent with a mixed acid-base disorder seen in diabetic ketoacidosis where metabolic acidosis from ketone production is partially compensated by respiratory acidosis from decreased alveolar ventilation due to emphysema. The other choices do not align with the given blood values. Choice B is incorrect as it would typically show respiratory alkalosis. Choice C would show respiratory alkalosis with low PaCO2. Choice D would result in metabolic acidosis with low HCO3.

Correct Answer: A

Rationale: The correct answer is A: Extravasation of the medication. Extravasation occurs when the infused medication leaks into surrounding tissues, potentially causing tissue damage and necrosis. This is a serious concern with vesicant medications like daunorubicin. If left untreated, it can lead to severe complications. Choice B: Discomfort to the patient is incorrect because while discomfort may occur with infiltration, the main concern is the potential for tissue damage from extravasation. Choice C: Blanching at the site is incorrect as it is a common sign of infiltration, but the main concern is the possibility of extravasation and tissue damage. Choice D: Hypersensitivity reaction to the medication is incorrect as it is a different type of reaction that is not directly related to infiltration or extravasation.

Correct Answer: C

Rationale: The correct answer is C because it includes foods high in potassium. Raisins, whole wheat toast, and milk are good sources of potassium. Sausage might contain some potassium as well. A: This option lacks potassium-rich foods. B: While strawberries have some potassium, the overall meal lacks a sufficient amount. D: While oatmeal and peaches have potassium, coffee can actually inhibit potassium absorption.

Correct Answer: D

Rationale: The correct answer is D: Fluid volume status. Assessment of specific gravity helps to determine the concentration of solutes in the urine, indicating the degree of hydration or dehydration. In SIADH, there is water retention leading to diluted urine, resulting in low specific gravity. Monitoring specific gravity every 4 hours is crucial in assessing the patient's fluid volume status and response to treatment. A: Nutritional status is not directly assessed by specific gravity. B: Potassium balance is not directly assessed by specific gravity. C: Calcium balance is not directly assessed by specific gravity.

Correct Answer: A

Rationale: The correct answer is A: Assess the airway. The nurse should prioritize airway assessment as the client's ABGs indicate respiratory acidosis (low pH, high PaCO2). This suggests potential airway obstruction or inadequate ventilation. Ensuring a patent airway is crucial for adequate oxygenation. Administering bronchodilators (B) or mucolytics (D) may help with airway clearance but should come after ensuring a clear airway. Providing oxygen (C) is important, but addressing the underlying respiratory acidosis by first assessing the airway is the priority in this situation to prevent further deterioration.