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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Cerebral bleeding. Choice A rationale:

Stress fractures are not directly related to hypernatremia. Hypernatremia is an electrolyte imbalance, and its main effects are related to cellular dehydration and neurological symptoms rather than bone fractures.

Choice B rationale:

This is the correct answer because hypernatremia can lead to severe dehydration and cause neurological complications, including cerebral bleeding. The brain cells can shrink due to water loss, causing blood vessels to rupture, leading to bleeding in the brain.

Choice C rationale:

Atrial dysrhythmias are not directly associated with hypernatremia. Hypernatremia primarily affects the central nervous system and can lead to neurological symptoms rather than cardiac dysrhythmias.

Choice D rationale:

Pulmonary edema is not a likely consequence of hypernatremia. Pulmonary edema is associated with fluid volume excess, not fluid volume deficit, which is characteristic of hypernatremia.

A. Potassium 3.3 mEq/L. B. HCO3- 30 mEq/L. C. PacO2 50 mm Hg. D. pH 7.45.

Correct Answer is C

Explanation

PacO2 50 mm Hg. Choice A rationale:

Potassium levels are not directly related to respiratory acidosis. Potassium levels may be affected in certain conditions, but they are not specific indicators of respiratory acidosis.

Choice B rationale:

HCO3- (bicarbonate) levels may be elevated in metabolic alkalosis, not respiratory acidosis. In respiratory acidosis, the primary abnormality is an increased PacO2, not HCO3-.

Choice C rationale:

The partial pressure of carbon dioxide (PacO2) is a key parameter in diagnosing respiratory acidosis. In this case, a PacO2 of 50 mm Hg suggests hypoventilation and an excess of carbon dioxide in the blood, contributing to acidosis.

Choice D rationale:

The pH level given (pH 7.45) is within the normal range, which contradicts the diagnosis of respiratory acidosis. In respiratory acidosis, the pH would be expected to be below the normal range of 7.35-7.45 due to increased carbon dioxide levels.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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

Correct Answer is C

Explanation

A nurse is reviewing the laboratory results for four clients. The nurse should recognize which of the following clients has a manifestation of hypoparathyroidism?

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?

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

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?