Try Naxlex NCLEX-RN (Free-Trial)

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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale: Patients with bulimia are at increased risk for developing metabolic alkalosis due to recurrent vomiting, which leads to loss of hydrochloric acid from the stomach and results in an elevated blood bicarbonate level.

Choice B rationale: Patients with COPD are more likely to develop respiratory acidosis due to retention of carbon dioxide, not metabolic alkalosis.

Choice C rationale: Patients with venous stasis ulcers do not have a direct association with metabolic alkalosis.

Choice D rationale: Patients on dialysis are more likely to experience metabolic acidosis due to impaired kidney function and inability to excrete acid effectively.

A. A client who has a phosphate of 5.7 mg/dL. B. A client who has a calcium of 9.8 mg/dL. C. A client who has a vitamin D of 25 ng/mL. D. A client who has a magnesium of 1.8 mEq/L.

Correct Answer is A

Explanation

Choice A rationale:

The client with a phosphate level of 5.7 mg/dL likely has a manifestation of hypoparathyroidism. Hypoparathyroidism leads to decreased parathyroid hormone (PTH) secretion, which causes increased renal phosphate reabsorption, leading to elevated phosphate levels in the blood.

Choice B rationale:

A calcium level of 9.8 mg/dL is within the normal range (8.5-10.2 mg/dL) and does not indicate hypoparathyroidism.

Choice C rationale:

A vitamin D level of 25 ng/mL is within the normal range (30-100 ng/mL) and does not suggest hypoparathyroidism.

Choice D rationale:

A magnesium level of 1.8 mEq/L is within the normal range (1.7-2.2 mEq/L) and does not directly indicate hypoparathyroidism.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

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?

Correct Answer is A

Explanation

A nurse is caring for a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

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 fluid overload is prescribed furosemide (Lasix) 20 mg by mouth each day. What should the nurse include when teaching the patient about this medication? Select all that apply.

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 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?

A nurse is reviewing the laboratory results of a client who takes furosemide. Which of the following results should the nurse identify as the priority finding?