The nurse analyzes the results of a patient’s arterial blood gases (ABGs). Which finding requires immediate action?

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Question 1 of 5

The nurse analyzes the results of a patient’s arterial blood gases (ABGs). Which finding requires immediate action?

Correct Answer: D

Rationale: The correct answer is D because a PaO2 level of 62 mm Hg indicates severe hypoxemia, which is a critical condition requiring immediate action to prevent tissue damage and organ failure. Normal PaO2 levels are around 80-100 mm Hg. A low PaO2 indicates poor oxygenation of the blood. Choice A (HCO3?2-) being slightly elevated is not an emergency but may indicate metabolic alkalosis. Choice B (SaO2) at 92% is within the normal range for most patients. Choice C (PaCO2) at 31 mm Hg is also within normal limits and suggests adequate ventilation. In summary, a low PaO2 level is the most critical finding that requires immediate intervention compared to the other choices.

Question 2 of 5

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that going out with friends is no longer enjoyable. How would the nurse respond?

Correct Answer: C

Rationale: The correct answer is C because it demonstrates therapeutic communication by encouraging the client to express their thoughts and feelings. This approach helps the nurse understand the underlying reasons for the client's behavior and can lead to addressing issues such as anxiety or depression. Option A is incorrect as it doesn't address the client's emotional needs. Option B is incorrect as prescribing medication should not be the first response to social withdrawal. Option D is incorrect as it overlooks the importance of exploring the client's emotional state. Overall, option C is the best choice as it promotes open communication and a holistic approach to addressing the client's concerns.

Question 3 of 5

The ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which of the following areas is unnecessary to emphasize when providing client education for blood pressure control?

Correct Answer: A

Rationale: The correct answer is A: Instruct the client to limit protein intake. Limiting protein intake is unnecessary for blood pressure control. Here's the rationale: 1. Sodium intake: Excessive salt intake can lead to high blood pressure, so teaching the client to avoid adding salt to foods is important. 2. Weight management: Excess weight can contribute to high blood pressure, so discussing weight reduction or maintenance is crucial. 3. Exercise: Regular physical activity can help lower blood pressure, making it important to stress the importance of an exercise program. 4. Protein intake: While a balanced diet is important for overall health, limiting protein intake specifically is not typically a key factor in blood pressure control.

Question 4 of 5

The nurse closely monitors for hypercalcemia, an oncologic emergency that is manifested by.

Correct Answer: B

Rationale: The correct answer is B: Fatigue, confusion, and weakness. Hypercalcemia is characterized by high levels of calcium in the blood, leading to neurological symptoms like fatigue, confusion, and weakness. This occurs due to the effect of excess calcium on the nervous system. Choices A, C, and D are incorrect as hypertension and bradycardia are not typical manifestations of hypercalcemia, laboratory results of potassium and sodium levels do not specifically indicate hypercalcemia, and decreased urine output is not a typical symptom of hypercalcemia.

Question 5 of 5

A young adult patient tells the health care provider about experiencing cold, numb fingers and Raynaud’s phenomenon is suspected. What type of testing should the nurse anticipate explaining to the patient?

Correct Answer: C

Rationale: The correct answer is C: Autoimmune disorders. Raynaud's phenomenon is characterized by cold, numb fingers due to vasoconstriction of blood vessels in response to cold or stress. It is often associated with autoimmune disorders like lupus or scleroderma. Testing for autoimmune disorders may include antinuclear antibody (ANA) testing, rheumatoid factor (RF) testing, and specific autoantibody testing. Explanation for why the other choices are incorrect: A: Hyperglycemia is high blood sugar levels, which is not directly related to Raynaud's phenomenon. B: Hyperlipidemia is high levels of fats in the blood, which is not directly related to Raynaud's phenomenon. D: Coronary artery disease is a condition of the heart's blood vessels, and it is not directly related to Raynaud's phenomenon.

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