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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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","C","E"]

Explanation

Choice A rationale:

Dysrhythmias are not a direct consequence of diabetic ketoacidosis (DKA) or the acid-base imbalance indicated by the patient's pH of 7.2 and bicarbonate level of 20 mEq/L. DKA primarily affects the respiratory system, leading to Kussmaul respirations, not dysrhythmias.

Choice B rationale:

Kussmaul respirations are an expected finding in a patient with diabetic ketoacidosis (DKA) and metabolic acidosis. These deep, rapid breaths are the body's attempt to compensate for the acidosis by eliminating excess CO2.

Choice C rationale:

Weakness is a common symptom of DKA. The hyperglycemia and acidosis result in intracellular dehydration and impaired cellular function, leading to weakness and fatigue.

Choice D rationale:

Cold, clammy skin is not typically associated with DKA. Instead, patients with DKA may have warm, dry skin due to dehydration and impaired thermoregulation.

Choice E rationale:

Tachycardia is an expected finding in a patient with DKA. The metabolic acidosis and dehydration lead to an increase in heart rate as the body attempts to maintain perfusion.

A. Romaine lettuce. B. Lean red meat. C. Almonds. D. White rice.

Correct Answer is ["A","C"]

Explanation

Choice A rationale:

Romaine lettuce is a good dietary source of magnesium. Since the patient has a low serum magnesium level, suggesting foods rich in magnesium like romaine lettuce can help improve magnesium levels.

Choice B rationale:

Lean red meat is not a good suggestion for a patient with low magnesium levels. While it contains magnesium, it is not as rich in magnesium as some other food choices.

Choice C rationale:

Almonds are a good dietary source of magnesium and can be recommended to the patient with low magnesium levels to help increase their magnesium intake.

Choice D rationale:

White rice is not a significant source of magnesium and may not be helpful in improving the patient's low magnesium levels.

Choice E rationale:

Seafood is a good source of various nutrients but is not particularly rich in magnesium compared to other options like almonds and romaine lettuce. Thus, it may not be the best suggestion for the patient's low magnesium levels.

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Naxlex Comprehensive Predictor Exams

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.

Correct Answer is ["B","C","E"]

Explanation

The patient who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this patient?

Correct Answer is ["A","C"]

Explanation

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?

A nurse is reviewing a client's laboratory values and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

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?

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 nurse is concerned that a patient recovering from a thyroidectomy is developing hypocalcemia. What findings did the nurse use to come to this conclusion? 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 nurse is assessing a client who has chronic kidney disease for fluid volume increase. Which of the following provides a reliable measure of fluid retention?