The nurse obtains a sample of a client's arterial blood gas (ABGs). Which of the following statements is NOT true about ABGs?

Correct Answer: D

Rationale: Arterial blood gases (ABGs) do not directly assess the client's electrolyte and fluid balance. ABGs primarily evaluate the client's acid-base balance and oxygenation status by measuring levels of pH, partial pressure of carbon dioxide (PCO2), and bicarbonate (HCO3) in the arterial blood. While ABGs can provide some information about blood parameters, such as oxygen saturation, they do not comprehensively assess electrolyte levels or fluid balance. To specifically assess electrolytes and fluid balance, additional tests like basic metabolic panels or comprehensive metabolic panels would be required.

Correct Answer: C

Rationale: Incident Reports (IRs) must be summarized monthly and stored in a secured cabinet for several reasons. Firstly, summarizing the IRs monthly allows for a consolidated overview of the incidents that have occurred, highlighting any recurring patterns or trends that may need to be addressed. By storing the summarized IRs in a secured cabinet, the information is kept confidential and protected from unauthorized access. This practice also ensures that the reports are organized and easily accessible for future reference or audits. Storing the IRs on an open cabinet, table top, or with a classification system that may not be easily understandable can lead to potential breaches of confidentiality or difficulty in retrieving and understanding the information when needed.

Correct Answer: C

Rationale: The most appropriate action for a concerned nurse when nurses are projected as sex symbols in a television advertisement is to make a position paper to denounce the advertisement. This approach allows the nurse to voice their concerns in a formal and professional manner. By creating a position paper, the nurse can clearly outline why the portrayal is inappropriate and advocate for more respectful representations of nursing in the media. This action is constructive, proactive, and focuses on initiating change through advocacy and education. It is a thoughtful and strategic way to address the issue and raise awareness about the importance of respecting the nursing profession.

Correct Answer: C

Rationale: The patient is most likely experiencing an acute myocardial infarction (MI) based on the presentation of crushing chest pain lasting longer than 20 minutes, diaphoresis, dyspnea, and ST-segment elevation on the ECG. These symptoms are consistent with the classic presentation of an ST-segment elevation myocardial infarction (STEMI), which is a type of acute MI that is characterized by prolonged ischemia leading to myocardial cell death. In this case, the ST-segment elevation in the anterior leads indicates myocardial damage in the corresponding area of the heart supplied by the affected coronary artery. This is a medical emergency that requires urgent intervention to restore blood flow to the affected myocardium and prevent further complications.

Correct Answer: C

Rationale: The appropriate ratio of chest compressions to rescue breaths for adult CPR is 30 compressions to 2 breaths. This means that after every 30 chest compressions, two rescue breaths should be given. This ratio helps in maintaining oxygen circulation in the body while also ensuring that the heart is being effectively pumped to circulate blood. The emphasis on chest compressions is critical in maintaining blood flow to vital organs during cardiac arrest, while the rescue breaths help in providing oxygen to the patient's lungs. This ratio is recommended by organizations like the American Heart Association for performing high-quality adult CPR.

Correct Answer: C

Rationale: Patients like Emmy who have experienced delayed hypersensitivity to latex typically present with symptoms such as rhinitis (runny or stuffy nose) and conjunctivitis (inflammation of the eyes). In addition, delayed hypersensitivity reactions often involve skin manifestations, such as blisters. These symptoms are reflective of the inflammatory response triggered by exposure to latex in individuals with delayed hypersensitivity. Symptoms like flushing, bronchospasm, urticaria, laryngeal edema, papules, vesicles, and pruritus are more commonly associated with immediate-type hypersensitivity reactions rather than delayed hypersensitivity reactions in latex-sensitive individuals.

Correct Answer: D

Rationale: Acute respiratory distress syndrome (ARDS) is a severe condition characterized by widespread inflammation in the lungs leading to increased pulmonary vascular permeability, non-cardiogenic pulmonary edema, and respiratory failure. In ARDS, the alveolar-capillary barrier is disrupted, resulting in fluid accumulation in the alveoli and impaired gas exchange.

Correct Answer: C

Rationale: When a nurse discovers a discrepancy between the medication order and the patient's medication record, the priority action is to verify the medication order with the prescriber to ensure accuracy and patient safety. Administering the medication without clarification can put the patient at risk. Documenting the discrepancy and informing the charge nurse is important, but it should not delay verifying the order with the prescriber. Contacting the pharmacy for clarification may be necessary in some cases, but the immediate action should be to confirm the prescription with the prescriber to prevent errors and ensure the patient receives the correct medication.

Correct Answer: B

Rationale: Periodontitis is the dental condition characterized by inflammation of the gingival tissues surrounding the teeth. It is typically caused by poor oral hygiene practices, leading to plaque buildup and eventually gum disease. If left untreated, periodontitis can cause serious damage to the gum tissue and the underlying bones supporting the teeth, which can eventually result in tooth loss. Regular dental check-ups, proper oral hygiene habits, and professional cleanings are important for preventing and managing periodontitis.