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.

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

Choice A rationale:

Increased urine ketones are not indicative of fluid volume deficit. Instead, they may suggest diabetic ketoacidosis or starvation ketosis.

Choice B rationale:

Decreased Hgb (hemoglobin) is not specific to fluid volume deficit and can be seen in various conditions such as anemia or bleeding.

Choice C rationale:

Decreased urine specific gravity is not consistent with fluid volume deficit, as it usually results in concentrated urine with increased specific gravity.

Choice D rationale:

An increased blood urea nitrogen (BUN) level is expected in fluid volume deficit due to reduced kidney perfusion and function. BUN is a marker of kidney function and is elevated when fluid volume is low.

A. Narcotic. B. Thiazide diuretic. C. Corticosteroid. D. Muscle relaxer.

Correct Answer is B

Explanation

Choice A rationale:

Narcotics are not known to directly cause hypokalemia. Their main effects are related to pain relief and central nervous system depression.

Choice B rationale:

Thiazide diuretics can cause potassium loss in the urine, leading to hypokalemia. These diuretics work by inhibiting sodium reabsorption in the distal convoluted tubule, which can lead to potassium excretion as well.

Choice C rationale:

Corticosteroids can cause sodium and water retention but are not typically associated with significant potassium abnormalities.

Choice D rationale:

Muscle relaxers are not known to cause hypokalemia. They primarily act on the neuromuscular junction and do not directly impact potassium levels.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

A patient is diagnosed with hypokalemia. After reviewing the patient's current medications, which drug should the nurse consider that might have contributed to the patient's health problem?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving IV fluids to correct dehydration. Which of the following laboratory values should indicate to the nurse that the client is effectively responding to treatment?

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

The nurse is planning care for a patient with severe burns. What health problem should the nurse realize that this patient could develop?

A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which electrolyte imbalance?

A patient with chronic renal failure has an occluded arteriovenous fistula, and routine hemodialysis is delayed. However, the patient's serum potassium level is 6.0 mEq/L. What should the nurse expect to be prescribed for this patient? Select all that apply.

A nurse is planning to teach a client about a high-potassium diet. Which of the following foods should the nurse instruct the client to eat? (Select all that apply.).

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 patient has a serum phosphate level of 2.0 mg/dL. Which treatments should the nurse expect to be prescribed for this patient? Select all that apply.