the nurse analyzes the results of a patients arterial blood gases abgs which finding would require immediate action
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Nursing Elites

NCLEX-RN

NCLEX RN Prioritization Questions

1. The nurse analyzes the results of a patient's arterial blood gases (ABGs). Which finding would require immediate action?

Correct answer: D

Rationale: While all the values are abnormal, the low PaO2 level of 59 mm Hg indicates that the patient is at a critical point on the oxyhemoglobin dissociation curve. At this level, a small decrease in PaO2 can lead to a significant drop in oxygen saturation and compromise tissue oxygenation. Therefore, immediate intervention is necessary to improve the patient's oxygenation status. Choice A (HCO3 of 31 mEq/L) may indicate metabolic alkalosis or compensation for respiratory acidosis; however, it does not require immediate action in this scenario. Choice B (SaO2 of 92%) is slightly low but not critically low to require immediate action. Choice C (PaCO2 of 31 mm Hg) is within the normal range and does not indicate immediate danger to the patient.

2. A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition?

Correct answer: C

Rationale: A client with a severe vitamin C deficiency has a condition called scurvy. Scurvy is characterized by symptoms such as bleeding gums, loose teeth, poor wound healing, and easy bruising. The correct answer is 'Bleeding gums and loose teeth' because these are classic signs of scurvy due to vitamin C deficiency. Choice A ('Cracks at the corners of the mouth') is more indicative of a deficiency in B vitamins, specifically riboflavin. Choice B ('Altered mental status') is not typically associated with vitamin C deficiency but can occur with other conditions like vitamin B12 deficiency. Choice D ('Anorexia and diarrhea') are not common symptoms of vitamin C deficiency, as they are more commonly associated with other gastrointestinal issues or deficiencies in different nutrients.

3. The nurse is caring for a woman 2 hours after a vaginal delivery. Documentation indicates that the membranes were ruptured for 36 hours prior to delivery. What are the priority nursing diagnoses at this time?

Correct answer: D

Rationale: The correct answer is 'Risk for infection.' When the membranes are ruptured for more than 24 hours prior to birth, there is a significantly increased risk of infection for both the mother and the newborn. Monitoring for signs of infection, such as fever, foul-smelling vaginal discharge, and uterine tenderness, is crucial. Option A, 'Altered tissue perfusion,' is not the priority in this scenario as infection risk takes precedence due to the prolonged rupture of membranes. Option B, 'Risk for fluid volume deficit,' is less of a priority compared to the immediate risk of infection. Option C, 'High risk for hemorrhage,' is not the priority concern at this time based on the information provided.

4. The nurse is reviewing the record of a child diagnosed with nephrotic syndrome. The nurse should expect to note which finding documented in the child's record?

Correct answer: B

Rationale: In nephrotic syndrome, a key finding documented in the child's record is weight gain due to massive edema. While urine may appear dark, foamy, and frothy, grossly bloody urine is not expected as only microscopic hematuria is present. Additionally, urine output is decreased, and hypertension is likely to be present. Therefore, the correct answer is weight gain as it aligns with the characteristic presentation of nephrotic syndrome.

5. The parents of a newborn with hypospadias are reviewing the treatment plan with the nurse. Which statement by the parents indicates their understanding of the plan?

Correct answer: D

Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. It's important not to circumcise the infant, as the dorsal foreskin tissue will be required for surgical repair of the hypospadias. Option A is unrelated to the treatment plan for hypospadias. Option B is not directly related to the surgical repair of hypospadias. Option C is not a routine part of the treatment plan for hypospadias, as catheterization is usually managed by healthcare professionals.

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