A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?

A client who told an assistive personnel he is short of breath

A client who received oral pain medication 30 min ago

A client who is scheduled for an abdominal x-ray and is awaiting transport

A client who has a prescription for discharge

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is correct because a client who is short of breath is in immediate danger, as it indicates a possible respiratory compromise or failure. The nurse should assess the client's oxygen saturation, respiratory rate, and lung sounds, and provide oxygen therapy as needed.

Choice B Reason: This is incorrect because a client who received oral pain medication 30 min ago is not in immediate danger, as it indicates that the client's pain has been managed and the medication has had time to take eﬀect.

Choice C Reason: This is incorrect because a client who is scheduled for an abdominal x-ray and is awaiting transport is not in immediate danger, as it indicates that the client's condition is stable and the diagnostic test is not urgent.

Choice D Reason: This is incorrect because a client who has a prescription for discharge is not in immediate danger, as it indicates that the client's condition has improved and the client is ready to leave the hospital.

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 B

Explanation

Choice A Reason: This is incorrect because the laboratory values are not within the expected reference range in a client who has DIC. DIC is a condition that causes abnormal activation of the clotting cascade, leading to widespread microthrombi formation and consumption of clotting factors and platelets. This results in bleeding complications and organ dysfunction.

Choice B Reason: This is correct because the laboratory values are prolonged in a client who has DIC. PT, aPTT, and INR are tests that measure the time it takes for blood to clot. PT measures the extrinsic pathway, aPTT measures the intrinsic pathway, and INR is a standardized ratio of PT. In DIC, these tests are prolonged because of the depletion of clotting factors and platelets.

Choice C Reason: This is incorrect because the laboratory values are not the same as the previous test values in a client who has DIC. DIC is an acute and dynamic condition that can change rapidly depending on the underlying cause and treatment. The laboratory values may ﬂuctuate between normal, prolonged, or shortened depending on the balance between clotting and bleeding.

Choice D Reason: This is incorrect because the laboratory values are not decreased in a client who has DIC. Decreased laboratory values would indicate a shortened clotting time, which can occur in some cases of DIC when there is excessive clotting and thrombosis. However, this is not the typical finding in DIC, as most clients present with bleeding manifestations and prolonged clotting time.

A. pH 7.49, HCO3 24, PaCO2 30 B. pH 7.26, HCO3 24, PaCO2 46 C. pH 7.26, HCO3 14, PaCO2 30 D. pH 7.49, HCO3 30, PaCO2 40

Correct Answer is C

Explanation

Choice A Reason: This choice is incorrect because it indicates respiratory alkalosis, not AKI. Respiratory alkalosis is a condition in which the lungs eliminate too much carbon dioxide (CO2) from the blood, resulting in a low level of CO2 (PaCO2) and a high level of pH. A normal PaCO2 range is 35 to 45 mm Hg, and a normal pH range is 7.35 to 7.45, so a value of 30 mm Hg and 7.49 indicate respiratory alkalosis.

Choice B Reason: This choice is incorrect because it indicates respiratory acidosis, not AKI. Respiratory acidosis is a condition in which the lungs cannot eliminate enough CO2 from the blood, resulting in a high level of CO2 (PaCO2) and a low level of pH. A value of 46 mm Hg and 7.26 indicate respiratory acidosis.

Choice C Reason: This choice is correct because it indicates metabolic acidosis, which is a common complication of AKI. Metabolic acidosis is a condition in which the body produces too much acid or loses too much base, resulting in a low level of bicarbonate (HCO3) and a low level of pH. A normal HCO3 range is 22 to 26 mEq/L, so a value of 14 mEq/L indicates metabolic acidosis. The low PaCO2 value (30 mm Hg) is due to the respiratory compensation mechanism that tries to restore the acid-base balance by increasing the ventilation and eliminating more CO2.

Choice D Reason: This choice is incorrect because it indicates metabolic alkalosis, not AKI. Metabolic alkalosis is a condition in which the body loses too much acid or gains too much base, resulting in a high level of bicarbonate (HCO3) and a high level of pH. A value of 30 mEq/L and 7.49 indicate metabolic alkalosis.

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

A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the PT, aPTT, and INR laboratory values for a client who is experiencing an acute episode of disseminated intravascular coagulation (DIC). Which of the following laboratory results should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?

Correct Answer is C

Explanation

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

A nurse in an emergency department is caring for an adult client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreﬂexia. Which of the following actions should the nurse take first?

A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?

A nurse in the emergency department is caring for a client who has sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?