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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 B

Explanation

The correct answer is B. 600 milliliters.

Choice A rationale:

A 24-hour urine output of 1000 milliliters is within the normal range for an adult, indicating adequate kidney function and hydration.

Choice B rationale:

A 24-hour urine output of 600 milliliters is below the normal range (typically 800-2000 milliliters), which may indicate oliguria (reduced urine output) and could be a sign of renal impairment or dehydration. This warrants notifying the healthcare provider.

Choice C rationale:

A 24-hour urine output of 1200 milliliters is also within the normal range, suggesting normal kidney function and hydration status.

Choice D rationale:

A 24-hour urine output of 750 milliliters is slightly below the normal range but may not be immediately concerning unless accompanied by other symptoms. However, it is still important to monitor and possibly notify the healthcare provider if it persists.

A. Request a dietitian consult for selecting foods high in phosphorous. B. Provide aluminum hydroxide antacids as prescribed. C. Instruct the patient to avoid poultry, peanuts, and seeds. D. Instruct the patient to avoid the intake of sodium phosphate.

Correct Answer is A

Explanation

Choice A rationale:

Hypophosphatemia is a condition characterized by low levels of phosphate in the blood, which can be caused by various factors, including malnutrition. In this case, the patient has a history of stomach ulcers, which might have contributed to poor nutrient absorption. The nurse should request a dietitian consult to ensure the patient receives an appropriate diet rich in phosphorus, which is essential for cellular function, bone health, and energy metabolism.

Choice B rationale:

Providing aluminum hydroxide antacids as prescribed is not the appropriate intervention for hypophosphatemia. Aluminum hydroxide antacids can bind to phosphate in the gastrointestinal tract, reducing its absorption and potentially worsening the patient's already low phosphate levels.

Choice C rationale:

Instructing the patient to avoid poultry, peanuts, and seeds is not suitable for this situation. These foods are good sources of phosphorus, and avoiding them would further deplete the patient's already low phosphate levels.

Choice D rationale:

Instructing the patient to avoid the intake of sodium phosphate is not necessary for hypophosphatemia. While sodium phosphate preparations are used as laxatives, there is no indication that the patient is taking them, and they are not relevant to the management of hypophosphatemia.

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Naxlex Comprehensive Predictor Exams

A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output volumes should the nurse notify the patient's healthcare provider?

Correct Answer is B

Explanation

A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. What intervention should the nurse include in this patient's plan of care?

Correct Answer is A

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?

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

A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Select all that apply.

A patient experiencing multisystem fluid volume deficit has tachycardia, pale, cool skin, and decreased urine output. The nurse realizes these findings are most likely a direct result of which process?

The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply.

A patient is admitted with hypernatremia caused by being stranded on a boat in the Atlantic Ocean for five days without a fresh water source. What is this patient at risk for developing?

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22, PacO₂ 68 mm Hg, Base excess -2, PaO₂ 78 mm Hg, Saturation 80%, Bicarbonate 26 mEq/L.

A nurse is caring for a client who has metabolic alkalosis. For which of the following clinical manifestations should the nurse monitor? (Select all that apply.).