a patient in metabolic alkalosis is admitted to the emergency department and pulse oximetry spo2 indicates that the o2 saturation is 94 which action s
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Prioritization Questions

1. A patient in metabolic alkalosis is admitted to the emergency department, and pulse oximetry indicates that the O2 saturation is 94%. Which action should the nurse take next?

Correct answer: C

Rationale: In a patient with metabolic alkalosis and an O2 saturation of 94%, placing the patient on high-flow oxygen is the correct action. Even though the O2 saturation seems adequate, metabolic alkalosis causes a left shift in the oxyhemoglobin dissociation curve, reducing oxygen delivery to tissues. Therefore, providing high-flow oxygen can help compensate for this. Administering bicarbonate would exacerbate the alkalosis. While completing a head-to-toe assessment and obtaining repeat ABGs are important interventions, the priority in this scenario is to improve oxygen delivery by placing the patient on high-flow oxygen.

2. After performing an assessment of an infant with bladder exstrophy, the nurse prepares a plan of care. The nurse identifies which problem as the priority for the infant?

Correct answer: B

Rationale: In bladder exstrophy, the bladder is exposed and external to the body, leading to impaired tissue integrity related to the exposed bladder mucosa as the priority problem. Urinary incontinence is not a concern as the infant is not yet toilet trained. Inability to suck and swallow is unrelated to the disorder. While educating the parents about the condition is important, it is not the priority over addressing the immediate risk of impaired tissue integrity in the infant.

3. A patient asks a nurse, "My doctor recommended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acid?'

Correct answer: A

Rationale: Green vegetables and liver are rich sources of folic acid. Green vegetables like spinach, asparagus, and broccoli are high in folic acid content. Liver, especially from chicken or beef, is also a good source of folic acid. Yellow vegetables and red meat (choice B) do not contain as high a concentration of folic acid as green vegetables and liver. Carrots (choice C) are nutritious but do not have the highest concentration of folic acid. Milk (choice D) is not a significant source of folic acid compared to green vegetables and liver.

4. An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?

Correct answer: A

Rationale: Infants typically double their birth weight by 6 months of age as part of normal growth and development. This doubling of weight is a common milestone used by healthcare providers to assess a baby's growth progress. Tripling the birth weight or adding 2 pounds each month would result in excessive weight gain, which is not typical or healthy for an infant. Similarly, gaining 6 ounces each week would also lead to rapid and abnormal weight gain, making it an incorrect choice.

5. The nurse is caring for a 10-year-old upon admission to the burn unit. One assessment parameter that will indicate that the child has adequate fluid replacement is

Correct answer: A

Rationale: The correct answer is urinary output of 30 ml per hour. In a 10-year-old child, this level of urinary output is indicative of adequate fluid replacement without suggesting overload. Monitoring urinary output is crucial in assessing fluid balance. Choices B, C, and D are incorrect. No complaints of thirst do not provide a direct assessment of fluid status. Increased hematocrit is a sign of dehydration, not adequate fluid replacement. Good skin turgor around the burn is a general assessment but may not directly reflect the child's overall fluid status.

Similar Questions

A patient asks a nurse administering blood how long red blood cells live in the body. What is the correct response?
While receiving normal saline infusions to treat a GI bleed, the nurse notes that the patient's lower legs have become edematous and auscultates crackles in the lungs. What should the nurse do first?
A patient has been diagnosed with acute gastritis in a clinic. Which of the following medications would be contraindicated for this patient?
A mother has recently been informed that her child has Down syndrome. You will be assigned to care for the child at shift change. Which of the following characteristics is not associated with Down syndrome?
Which of the following techniques can help to prevent skin irritation or breakdown around a tracheostomy site?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses