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A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?

Prepare to administer a sedative.

Prepare for mechanical ventilation.

Massage the calf area for tenderness.

Assess for indications of pulmonary embolism.

None

Answer and Explanation

The Correct Answer is D

The correct answer is d. Assess for indications of pulmonary embolism.

Choice A rationale:

Administering a sedative is not appropriate as the priority intervention. Sedatives can depress respiratory function, which is already compromised in this patient.

Choice B rationale:

Preparing for mechanical ventilation might be necessary if the patient’s condition worsens, but it is not the immediate priority. The priority is to identify the underlying cause of the symptoms.

Choice C rationale:

Massaging the calf area for tenderness is not relevant in this context. While calf tenderness can be a sign of deep vein thrombosis (DVT), which can lead to pulmonary embolism, the immediate priority is to assess for pulmonary embolism directly.

Choice D rationale:

Assessing for indications of pulmonary embolism is the priority because the patient’s symptoms (shortness of breath, chest pain, recent use of birth control pills, smoking history, and abnormal ABG values) strongly suggest a pulmonary embolism. Early identification and treatment are crucial to prevent further complications.

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Correct Answer is D

Explanation

The correct answer isd. Assess for indications of pulmonary embolism.

Choice A rationale:

Administering a sedative is not appropriate as the priority intervention. Sedatives can depress respiratory function, which is already compromised in this patient.

Choice B rationale:

Preparing for mechanical ventilation might be necessary if the patient’s condition worsens, but it is not the immediate priority. The priority is to identify the underlying cause of the symptoms.

Choice C rationale:

Choice D rationale:

Assessing for indications of pulmonary embolism is the priority because the patient’s symptoms (shortness of breath, chest pain, recent use of birth control pills, smoking history, and abnormal ABG values) strongly suggest a pulmonary embolism.Early identification and treatment are crucial to prevent further complications.

A. 10 mg/dL. B. 18 mg/dL. C. 13 mg/dL. D. 25 mg/dL.

Correct Answer is D

Explanation

25 mg/dL.

Choice A rationale:

A BUN (Blood Urea Nitrogen) level of 10 mg/dL is within the normal range, indicating normal kidney function. There is no indication to report this value to the provider for a dehydrated client.

Choice B rationale:

A BUN level of 18 mg/dL is within the normal range as well. This value does not suggest significant dehydration, so it is not necessary to report it to the provider in this context.

Choice C rationale:

A BUN level of 13 mg/dL is also within the normal range, and similar to choices A and B, it does not indicate severe dehydration that requires immediate reporting to the provider.

Choice D rationale:

A BUN level of 25 mg/dL is elevated, which may indicate dehydration, kidney dysfunction, or other issues affecting fluid balance. Since the client is dehydrated, this elevated value needs to be reported to the provider for further evaluation and appropriate intervention.

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider?

Correct Answer is D

Explanation

The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. Which intervention should the nurse expect to be prescribed to correct this problem?

A patient with atrial fibrillation and a serum potassium level of 3.0 mEq/L takes digoxin (Lanoxin), ASA (aspirin), KCL (potassium chloride), and warfarin (Coumadin) daily. The patient reports visual disturbances. The nurse suspects problems with which medication?

A nurse is teaching a client who is on a low-sodium diet. Which of the following instructions should the nurse include? (Select All that Apply.).

A nurse is assessing a client who has fluid volume deficit. The nurse should expect which of the following findings?

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?

The nurse is reviewing the health problems for a group of assigned patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis?

A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?