Nursing Elites

1. In a client with asthma who develops respiratory acidosis, what should the nurse expect the client's serum potassium level to be?

• A. normal
• B. elevated
• C. low
• D. unrelated to the pH

Correct answer: B

Rationale: In respiratory acidosis, the serum potassium level is expected to be elevated. This occurs because potassium shifts from cells into the bloodstream as a compensatory mechanism to maintain acid-base balance. Choices A, C, and D are incorrect. A normal potassium level is not expected in respiratory acidosis. A low potassium level is more commonly associated with alkalosis, not acidosis. The potassium level is indeed related to pH changes in respiratory acidosis, leading to the expected elevation.

2. A pregnant Asian client who is experiencing morning sickness wants to take ginger to relieve the nausea. Which of the following responses by the nurse is appropriate?

• A. "I will call your physician to see if we can start some ginger."?
• B. "We don't use home remedies in this clinic."?
• C. "Herbs are not as effective as regular medicines."?
• D. "Just eat some dry crackers instead."?

Correct answer: A

Rationale: The correct response is appropriate as it demonstrates cultural sensitivity. Ginger is commonly used to alleviate nausea, particularly in Asian cultures. Contacting the physician to discuss the use of ginger ensures the client's safety and respects their preferences. Choices B and C are incorrect as they disregard the client's request and fail to acknowledge their cultural beliefs. Choice D is incorrect because it does not address the client's desire to use ginger for relief.

3. A 13-year-old girl is admitted to the ER with lower right abdominal discomfort. What should the admitting nurse do first?

• A. Administer Loritab to the patient for pain relief.
• B. Place the patient in a right sidelying position for pressure relief.
• C. Start a Central Line.
• D. Provide pain reduction techniques without administering medication.

Correct answer: D

Rationale: In a case of lower right abdominal discomfort, the first step should be to provide pain reduction techniques without administering medication. Administering pain medication or starting a central line should not be done without medical orders. Placing the patient in a right sidelying position may help with pressure relief, but addressing pain reduction techniques without medication is the initial priority in this scenario. It is essential to assess the patient further, consult with a healthcare provider, and follow the appropriate protocols before administering any medication or invasive procedures like starting a central line.

4. Which of the following observations is most important when assessing a client's breathing?

• A. presence of breathing and pulse rate
• B. breathing pattern and adequacy of breathing
• C. presence of breathing and adequacy of breathing
• D. patient position and adequacy of breathing

Correct answer: C

Rationale: The correct answer is the presence of breathing and adequacy of breathing. It is crucial not only to confirm that the client is breathing but also to ensure that the breathing is adequate for proper oxygenation. Choices A, B, and D are incorrect because while pulse rate, breathing pattern, and patient position are relevant aspects to consider, the most critical observations in assessing a client's breathing are the presence and adequacy of breathing.

5. What could be a possible cause for the symptoms experienced by the client in Question 28?

• A. iron deficiency
• B. folate deficiency
• C. peptic ulcer
• D. iron overload

Correct answer: A

Rationale: Given the client's symptoms of fatigue, shortness of breath, and lightheadedness, along with her gender and fad dieting, the most likely cause is iron deficiency. Iron deficiency commonly presents with these symptoms due to decreased oxygen-carrying capacity in the blood. Folate deficiency would typically present with different symptoms such as mouth sores and changes in skin, not fitting the client's presentation. Peptic ulcer would manifest with abdominal pain, not primarily with the symptoms described. Iron overload would present with symptoms such as joint pain and fatigue, which are not consistent with the client's presentation.

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