A nurse is assisting with the care of client.
Drag 1 condition and 1 finding to fill in each blank in the following sentences
The client likely suffered from
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Condition: Opioid intoxication – The client's presentation of unresponsiveness, respiratory depression (RR 10/min), and miosis (pinpoint pupils) is consistent with opioid intoxication. Additionally, the presence of a needle in the antecubital space suggests recent intravenous drug use.
Finding: Pupil characteristics – Opioid intoxication commonly causes miosis (pinpoint pupils), which was observed in the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) pH 7.36 (7.35 to 7.45), PaCO2 38 mm Hg (35 to 45 mmHg), HCO3 25 mEq/L (22 to 26 mEq/L): This is a normal set of arterial blood gas (ABG) values, with a pH within normal range, a normal PaCO2, and a normal HCO3. It does not suggest metabolic alkalosis.
B) pH 7.48 (7.35 to 7.45), PaCO2 32 mm Hg (35 to 45 mm Hg), HCO3 24 mEq/L (22 to 26 mEq/L): Although the pH is elevated, indicating alkalosis, the PaCO2 is slightly low, and the bicarbonate (HCO3) is within the normal range. This set of values does not indicate metabolic alkalosis, but could indicate respiratory alkalosis or compensated alkalosis.
C) pH 7.46 (7.35 to 7.45), PaCO2 36 mm Hg (35 to 45 mm Hg), HCO3 29 mEq/L (22 to 26 mEq/L): This is consistent with metabolic alkalosis. The elevated pH (alkalosis) combined with an increased bicarbonate level (HCO3 > 26 mEq/L) and a normal PaCO2 suggests metabolic alkalosis, as the kidneys retain bicarbonate to compensate for the condition.
D) pH 7.26 (7.35 to 7.45), PaCO2 35 mm Hg (35 to 45 mm Hg), HCO3 18 mEq/L (22 to 26 mEq/L): This set of values indicates acidosis, not alkalosis. The pH is low, indicating acidosis, and the bicarbonate (HCO3) is also low, which suggests metabolic acidosis. The PaCO2 is normal, which further supports a metabolic origin of the acidosis.
Correct Answer is D
Explanation
A) "Document the infiltration.": While documenting the infiltration is important for medical records, it is not the most immediate action to take. The nurse’s first priority should be to stop the infusion to prevent further complications such as tissue damage or excessive fluid accumulation around the insertion site.
B) "Elevate the arm.": Elevating the arm may help with swelling if the infiltration is mild, but it does not address the primary issue of preventing further fluid leakage. Stopping the infusion is the priority action to stop the infiltration from worsening.
C) "Apply a warm compress.": A warm compress can help with the absorption of infiltrated fluid, but it should not be applied until the infusion is stopped. If the infusion continues while a compress is applied, it could lead to further tissue damage and more discomfort for the client.
D) "Stop the infusion.": The first action should be to stop the IV infusion to prevent further infiltration. This stops the flow of fluid into the tissue, which is crucial in minimizing the risk of tissue damage and complications. After stopping the infusion, the nurse can assess the site, document the findings, and take additional actions, such as applying a warm compress or elevating the arm.
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