The nurse provides care to a patient admitted with a respiratory disorder. Which laboratory finding is most concerning?
Oxygen saturation 96%
Blood pH 7.32
Hemoglobin level 12 mg/dL
PaO2 80 mm Hg
The Correct Answer is B
A. Oxygen saturation 96%. This is a normal oxygen saturation level, so it is not a concern.
B. Blood pH 7.32. A pH below 7.35 indicates acidosis, which is concerning in a patient with a respiratory disorder, as it may indicate respiratory failure.
C. Hemoglobin level 12 mg/dL. This is a normal hemoglobin level for most adults and does not indicate a critical problem.
D. PaO2 80 mm Hg. While slightly lower than the normal range (normal is 80–100 mm Hg), this is not the most concerning finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Hypotension, urinary retention, and blurred vision: These symptoms are more characteristic of anticholinergic toxicity rather than serotonin syndrome.
B. Dizziness, lethargy, and headache: These symptoms are non-specific and do not define serotonin syndrome, which involves neuromuscular, autonomic, and mental status changes.
C. Hypomania, arrhythmias, and panic attacks:. While serotonin syndrome can cause agitation, it does not cause hypomania (a mild form of mania). Arrhythmias can occur but are not a hallmark symptom.
D. Confusion, restlessness, tachycardia, and diaphoresis: Serotonin syndrome is characterized by mental status changes (confusion, agitation), autonomic instability (tachycardia, hypertension, hyperthermia), and neuromuscular abnormalities (hyperreflexia, tremors, clonus).
Correct Answer is C
Explanation
A. Verifying the information with the patient's family members at the bedside: While family members can provide insight, the most critical step is gathering information directly from the patient about the reaction.
B. Placing an alert bracelet on the patient before leaving the unit: While this is necessary, the nurse should first confirm the details of the allergy.
C. Asking the patient to describe the reaction that occurs: The nurse must determine whether the reaction is a true allergy (e.g., anaphylaxis, rash, difficulty breathing) or an intolerance (e.g., nausea, drowsiness). This ensures appropriate precautions are taken.
D. Documenting the information on the patient's medical record: Documentation is crucial but should follow verification of the allergy details.
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