Nursing Elites

1. A healthcare professional is reviewing ABG laboratory results of a client who is in respiratory distress. The results are pH 7.47, PaCO2 32 mm Hg, and HCO3 22 mm Hg. The healthcare professional should recognize that the client is experiencing which of the following acid-base imbalances?

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

Correct answer: B

Rationale: The ABG results show a high pH (alkalosis) along with low PaCO2 and normal HCO3 levels, indicating respiratory alkalosis. In this condition, there is excessive loss of carbon dioxide (as seen by the low PaCO2) leading to a decrease in carbonic acid concentration and subsequent increase in pH. Metabolic acidosis or alkalosis would involve primary changes in bicarbonate levels, which are not predominant in this case.

2. The physician orders a platelet count to be performed on Mrs. Smith after breakfast. The nurse is responsible for:

• A. Instructing the patient about this diagnostic test
• B. Writing the order for this test
• C. Giving the patient breakfast
• D. All of the above

Correct answer: A

Rationale: The nurse's responsibility in this scenario is to instruct the patient about the diagnostic test ordered by the physician. This includes explaining the purpose of the test, any necessary preparations, and what to expect. The nurse is not responsible for writing the order, as this is the physician's role. Additionally, providing breakfast is not directly related to the platelet count test. Therefore, the correct answer is A, which aligns with the nurse's role in educating and supporting the patient regarding the test.

3. When caring for a client who speaks a language different from their own, what action should the nurse take?

• A. Request an interpreter of a different sex from the client.
• B. Request a family member or friend to interpret information for the client.
• C. Direct attention toward the interpreter when speaking to the client.
• D. Review the facility policy about the use of an interpreter.

Correct answer: D

Rationale: When caring for a client who speaks a different language, it is essential for the nurse to review the facility policy about the use of an interpreter. Using a professional interpreter ensures accurate communication and protects the client's confidentiality. Requesting an interpreter of a specific sex or relying on family members or friends can lead to miscommunication or breaches of confidentiality. Directing attention towards the interpreter helps facilitate communication but does not address the need for a professional interpreter as per facility policy.

4. In Maslow’s hierarchy of physiological needs, the human need of greatest priority is:

• A. Love
• B. Elimination
• C. Nutrition
• D. Oxygen

Correct answer: D

Rationale: In Maslow’s hierarchy of physiological needs, the most basic and immediate need is physiological survival, which includes the need for oxygen. Without oxygen, the body cannot survive for more than a few minutes, making it the highest priority physiological need according to Maslow's hierarchy.

5. A client who is at 38 weeks gestation, is in active labor, and has ruptured membranes is being cared for by a nurse. What action should the nurse take?

• A. Insert an indwelling urinary catheter
• B. Apply fetal heart rate monitor
• C. Initiate fundal massage
• D. Initiate an oxytocin IV infusion

Correct answer: B

Rationale: When caring for a client in active labor with ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This helps monitor the well-being of the fetus during labor and delivery, enabling timely interventions if any fetal distress is detected. Inserting an indwelling urinary catheter may be required in some cases, but it is not the priority in the given scenario. Fundal massage is typically done after delivery to help the uterus contract and prevent postpartum hemorrhage. Initiating an oxytocin IV infusion may be indicated to augment labor, but it is not the initial action needed in this situation.

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