Colleen, a 19 year old Freshman, was drinking alcohol at a frat party. She stupors, falls and hits her head on the ground. Her friend Julie dials "911" because Colleen is now unconscious, depressed ventilation (shallow and slow respirations), rapid heart rate, and is profusely bleeding from both ears. Which primary acid-base imbalance is Colleen at risk for if medical attention is not provided?

Metabolic Acidosis

Respiratory Acidosis

Respiratory Alkalosis

Metabolic Alkalosis

Answer and Explanation

The Correct Answer is B

Respiratory acidosis is a primary acid-base imbalance that occurs when there is an excess of carbon dioxide (CO2) in the body due to impaired ventilation or inadequate removal of CO2 from the lungs. In this case, Colleen's depressed ventilation, indicated by shallow and slow respirations, can lead to inadequate elimination of CO2 from her body. The excessive CO2 levels can result in an accumulation of carbonic acid (H2CO3) in the blood, leading to an increase in acidity and a decrease in pH.

The profuse bleeding from both ears indicates a potential head injury, which can lead to decreased neurological function and impaired control over the respiratory center in the brain. This can further contribute to depressed ventilation and the development of respiratory acidosis. Metabolic acidosis, characterized by a decrease in bicarbonate (HCO3-) levels or an increase in non-carbonic acids in the blood, is not the primary acid-base imbalance in this case since the scenario does not provide information indicating a primary metabolic disorder. Respiratory alkalosis, characterized by decreased levels of CO2 in the blood, leading to increased pH and alkalinity, is not the primary acid-base imbalance in this case. The depressed ventilation and associated increase in CO2 levels indicate the opposite, respiratory acidosis. Metabolic alkalosis, characterized by an increase in bicarbonate levels or a decrease in non-carbonic acids, is not the primary acid-base imbalance in this case as the scenario does not provide information indicating a primary metabolic disorder.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Excessive exposure to UV light, such as sunlight or tanning beds, is a known trigger for SLE exacerbations. It is important for individuals with SLE to protect their skin from the sun by wearing protective clothing, using sunscreen, and avoiding direct sunlight during peak hours. Having a family history of SLE increases the risk of developing the disease. While it is not a trigger in itself, it is an important piece of information for the client to be aware of, as it may indicate a genetic predisposition to the condition.

Acetaminophen is a commonly used over-the-counter pain reliever. While it can help manage pain associated with SLE, it is not typically considered a trigger for exacerbations. Menopause, which marks the end of a woman's reproductive years, does not directly trigger SLE exacerbations. However, hormonal changes during menopause can potentially affect disease activity in some individuals. It is important for the client to discuss any changes or concerns with their healthcare provider to manage their symptoms effectively.

A. Black B. Green C. Yellow D. Red

Correct Answer is D

Explanation

The red tag is used to identify patients with critical injuries who require immediate medical attention. These individuals have life-threatening conditions that, with prompt medical intervention, have a higher chance of survival.

The triage color code system typically follows the following priority order:

1. Red tag: Immediate or emergent care needed for life-threatening injuries or conditions.

2. Yellow tag: Urgent care needed for significant injuries or conditions that are not immediately life-threatening.

3. Green tag: Non-urgent care needed for minor injuries or illnesses that can wait for medical treatment.

4. Black tag: Comfort care or deceased, as the injuries or conditions are incompatible with life or resources are not available for treatment.

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Naxlex Comprehensive Predictor Exams

The nurse caring for a client with systemic lupus erythematosus (SLE) would include which information in teaching about triggers that can result in an exacerbation of the disease?

Correct Answer is C

Explanation

You're working as a triage nurse during a disaster situation. Based on the triage color code tags placed on each of the wounded, which tag color represents the wounded who has the highest priority of being treated first?

Correct Answer is D

Explanation

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) and is diagnosed with pneumonia. The client has been on a long-term regimen of methylprednisolone. Which precautions should the nurse take to prevent complications? Select all that apply.

Based on the diagnosis of Dehydration, select which IV solution will be ordered to treat waiting this patient.

The patient who is confined to bed in the supine position has gained 5 lbs. in the last 48 hours. In which area does the nurse assess skin turgor for accurate determination of dependent edema?

Match using the choices provided:

In reviewing the electrolytes of a patient, the nurse notes the serum potassium level has increased from 4.3 mEq/L to 5.9 mEq/L. Which assessment does the nurse initiate first to prevent further harm?

A client is suffering from osteoarthritis in the knees and the nurse is providing care. The nurse is assessing the client's pain level and pain tolerance. Based on the nurse's understanding of pain, the nurse knows that a client's pain tolerance is most likely relieved by which of the following?

The nurse is delegating ambulation for a client to an experienced Patient Care Technician (PCT).Which teaching will the nurse provide to the PCT? (Select all that apply.)