A nurse is receiving report on a group of clients. Which of the following clients should the nurse assess first?

A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10.

A client who received parenteral cephalosporin and reports urticaria and edema.

A client who is being admitted with bilateral stage 3 pressure injuries on both heels.

A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F).

Answer and Explanation

The Correct Answer is B

Choice A Reason

A client who has a chest tube and reports a pain level of 6 on a scale of 0 to 10. While pain management is important, this client is not in immediate life-threatening danger. Pain can be addressed after ensuring there are no urgent allergic reactions or other critical conditions.

Choice B Reason

A client who received parenteral cephalosporin and reports urticaria and edema. This is the correct choice. Urticaria (hives) and edema (swelling) can indicate an allergic reaction, which can progress to anaphylaxis, a life-threatening condition. Immediate assessment and intervention are required to prevent severe complications.

Choice C Reason

A client who is being admitted with bilateral stage 3 pressure injuries on both heels. While stage 3 pressure injuries are serious and require prompt attention, they do not pose an immediate life-threatening risk compared to a potential anaphylactic reaction.

Choice D Reason

A client who has a systemic infection and an oral temperature of 39.1°C (102.4°F). Although a systemic infection with a high fever is concerning and needs timely intervention, it is not as immediately life-threatening as a potential anaphylactic reaction.

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Correct Answer is A

Explanation

Choice A Reason

Diazepam IV is the correct choice for managing repeated tonic-clonic seizures, especially in the context of status epilepticus. Diazepam is a benzodiazepine that acts quickly to stop seizures by enhancing the effect of the neurotransmitter GABA. It is commonly used in emergency settings due to its rapid onset of action when administered intravenously.

Choice B Reason

Lorazepam PO is not the best choice in this scenario. While lorazepam is also a benzodiazepine effective in stopping seizures, the oral route is not suitable for immediate control of seizures. Intravenous administration is preferred for rapid action.

Choice C Reason

Diltiazem IV is incorrect. Diltiazem is a calcium channel blocker used primarily for managing hypertension and certain types of arrhythmias. It is not indicated for the treatment of seizures.

Choice D Reason

Clonazepam PO is not appropriate for immediate seizure control. Although clonazepam is a benzodiazepine used for seizure management, the oral route is not effective for rapid seizure termination. Intravenous administration of a benzodiazepine like diazepam or lorazepam is preferred.

A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

Correct Answer is B

Explanation

Choice A Reason:

Respiratory acidosis is characterized by a low pH (below 7.35) and an elevated PaCO₂ (above 45 mm Hg). This condition occurs when there is an accumulation of carbon dioxide in the blood due to hypoventilation or impaired lung function. In this case, the client’s pH is elevated, and PaCO₂ is low, which does not align with respiratory acidosis.

Choice B Reason:

Respiratory alkalosis is indicated by a high pH (above 7.45) and a low PaCO₂ (below 35 mm Hg). This condition results from hyperventilation, which causes excessive exhalation of carbon dioxide. The client’s ABG results show a pH of 7.50 and a PaCO₂ of 29 mm Hg, consistent with respiratory alkalosis.

Choice C Reason:

Metabolic acidosis is characterized by a low pH (below 7.35) and a low HCO₃ (below 21 mEq/L). This condition occurs due to an accumulation of acids or a loss of bicarbonate in the body. The client’s pH is elevated, and HCO₃ is within the normal range, which does not indicate metabolic acidosis.

Choice D Reason:

Metabolic alkalosis is indicated by a high pH (above 7.45) and a high HCO₃ (above 28 mEq/L). This condition results from an excess of bicarbonate or a loss of acids. The client’s pH is elevated, but HCO₃ is within the normal range, which does not support a diagnosis of metabolic alkalosis.

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A nurse is receiving report on a group of clients. Which of the following clients should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 minutes. After maintaining the client’s airway and turning the client on their side, which of the following medications should the nurse administer?

Correct Answer is A

Explanation

A nurse is caring for a client who is hyperventilating and has the following ABG results: pH 7.50 (7.35 to 7.45), PaCO₂ 29 mm Hg (35 to 45 mm Hg), and HCO₃ 25 mEq/L (21 to 28 mEq/L). The nurse should identify that the client has which of the following acid-base imbalances?

Correct Answer is B

Explanation

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