Nursing Elites

1. A client is brought to the emergency department by a neighbor. The client is lethargic and has a fruity odor on the breath. The client’s arterial blood gas (ABG) results are pH 7.25, PCO2 34 mm Hg, PO2 86 mm Hg, HCO3 14 mEq/L. Which of the following acid-base disturbances does the nurse recognize in these results?

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

Correct answer: A

Rationale: The correct answer is 'Metabolic acidosis.' Metabolic acidosis is characterized by a low pH (<7.35) and a low bicarbonate level (HCO3 <22 mEq/L). In this case, the client's ABG results show a pH of 7.25 and an HCO3 level of 14 mEq/L, indicating metabolic acidosis. The PCO2 of 34 mm Hg is normal, ruling out respiratory acidosis or alkalosis. The PO2 of 86 mm Hg is also within the normal range and is not indicative of a respiratory problem. Therefore, the client is experiencing metabolic acidosis based on the ABG results provided.

2. What types of medications should the healthcare provider expect to administer to a client during an acute respiratory distress episode?

• A. Vasodilators and hormones.
• B. Analgesics and sedatives.
• C. Anticoagulants and expectorants.
• D. Bronchodilators and steroids.

Correct answer: D

Rationale: During an acute respiratory distress episode, the priority is to widen air passages, increase air space, and reduce alveolar membrane inflammation. Therefore, the client would likely require bronchodilators to open up the airways and steroids to reduce inflammation. Vasodilators and hormones (Choice A) are not typically indicated in this situation. Analgesics and sedatives (Choice B) may be used for pain management and anxiety but are not primary treatments for respiratory distress. Anticoagulants and expectorants (Choice C) are not the main medications used during an acute respiratory distress episode and may not address the immediate needs of the client.

3. The nurse empties the nasogastric suction collection canister of a client who had a bowel resection the previous day and notes that 1000 ml of gastric secretions were collected in the last 4 hours. What condition is the client at risk for developing?

• A. Metabolic alkalosis
• B. Hyperkalemia
• C. Metabolic acidosis
• D. Hypoglycemia

Correct answer: A

Rationale: The correct answer is A: Metabolic alkalosis. Loss of gastric secretions, which contain stomach acid, can lead to metabolic alkalosis. Excessive loss of acid results in an increase in the blood pH, leading to alkalosis. Hyperkalemia (B) is an elevated potassium level and is not directly related to the loss of gastric secretions. Metabolic acidosis (C) is an acid-base imbalance characterized by low pH and bicarbonate levels, which is the opposite of what would occur with the loss of gastric secretions. Hypoglycemia (D) is low blood sugar and is not typically associated with the scenario described in the question.

4. A client with gastroesophageal reflux disease (GERD) has been experiencing severe reflux during sleep. Which recommendation by the nurse is most effective to assist the client?

• A. Losing weight.
• B. Decreasing caffeine intake.
• C. Avoiding large meals.
• D. Raising the head of the bed on blocks.

Correct answer: D

Rationale: The correct answer is to raise the head of the bed on blocks (reverse Trendelenburg position). This elevation helps reduce reflux by using gravity to keep stomach contents from flowing back into the esophagus during sleep. Losing weight (Choice A) could be beneficial in managing GERD, but it may not be as effective for immediate relief during sleep. Decreasing caffeine intake (Choice B) and avoiding large meals (Choice C) are also valuable recommendations to manage GERD; however, they may not specifically address the issue of reflux during sleep as directly and effectively as elevating the head of the bed.

5. Which of the following is the most important nursing action when administering a blood transfusion?

• A. Monitoring the patient's blood pressure.
• B. Monitoring the patient's temperature.
• C. Monitoring the patient's heart rate.
• D. Monitoring the patient's oxygen saturation.

Correct answer: A

Rationale: The most important nursing action when administering a blood transfusion is monitoring the patient's blood pressure. This is crucial because monitoring blood pressure allows for the prompt identification of any signs of adverse transfusion reactions, such as transfusion reactions or fluid overload. Immediate intervention can be initiated if any complications arise. While monitoring temperature, heart rate, and oxygen saturation are also essential aspects of patient care, they are not as critical as blood pressure monitoring during a blood transfusion. Therefore, the correct answer is to monitor the patient's blood pressure.

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