A nurse has received change-of-shift report on four clients.
Which of the following clients should the nurse plan to see first?
A client who is short of breath.
A client who received pain medication 30 min ago.
A client who is to be discharged at 11:00.
A client who is ambulatory and going for an x-ray at 10:00.
The Correct Answer is A
Choice A rationale:
A client who is short of breath is experiencing a life-threatening situation and should be seen first.
Choice B rationale:
A client who received pain medication 30 min ago is likely to be comfortable and can be seen later.
Choice C rationale:
A client who is to be discharged at 11:00 can be seen closer to the discharge time.
Choice D rationale:
A client who is ambulatory and going for an x-ray at 10:00 can be seen after the x-ray.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Metabolic alkalosis is incorrect because it would present with a high pH and high HCO3. This client’s pH is low, indicating acidosis, not alkalosis.
Choice B rationale:
Respiratory acidosis is correct. It is characterized by a low pH and high PaCO2, as seen in this client’s results. This condition occurs when the lungs can’t remove enough CO2, causing it to build up in the blood and lower the pH.
Choice C rationale:
Metabolic acidosis is incorrect because it would present with a low pH and low HCO3. This client’s HCO3 is normal.
Choice D rationale:
Respiratory alkalosis is incorrect because it would present with a high pH and low PaCO2. This client’s pH is low and PaCO2 is high.
Correct Answer is C
Explanation
Choice A rationale:
Metabolic alkalosis is incorrect because it would present with a high pH and high HCO3, which is not the case here.
Choice B rationale:
Respiratory acidosis is incorrect because it would present with a low pH and high PaCO2, which is not the case here.
Choice C rationale:
Metabolic acidosis is correct because it presents with a low pH and low HCO3, which matches the client’s ABG results.
Choice D rationale:
Respiratory alkalosis is incorrect because it would present with a high pH and low PaCO2, which is not the case here.
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