Nursing Elites

1. A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. Which acid-base imbalance does the nurse anticipate the client developing?

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

Correct answer: B

Rationale: The correct answer is B: Respiratory alkalosis. Hyperventilation from anxiety or fear causes an excessive loss of CO2, leading to respiratory alkalosis. This shift in pH results from the rapid, shallow breathing that reduces the level of carbon dioxide in the blood. Respiratory acidosis would occur in cases of poor ventilation or CO2 retention, while metabolic acidosis/alkalosis relates to disturbances in bicarbonate, not breathing patterns. Therefore, in this case, the client's hyperventilation due to anxiety would likely result in respiratory alkalosis, making option B the correct choice.

2. A client is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Which information in the client's history requires follow-up by the nurse?

• A. Is allergic to shellfish
• B. Has a history of smoking
• C. Takes metformin for type 2 diabetes mellitus
• D. Has hypertension controlled with medication

Correct answer: A

Rationale: An allergy to shellfish often indicates an allergy to iodine, which is used in contrast dyes for CT scans. This poses a significant risk of an allergic reaction during the procedure. The nurse must ensure appropriate precautions or alternative imaging are considered. Choices B, C, and D are not directly contraindicated for a CT scan with contrast. Smoking history, metformin use, and controlled hypertension do not typically impact the safety or feasibility of the procedure.

3. A client is receiving lactulose for signs of hepatic encephalopathy. To evaluate the therapeutic response, which assessment should the nurse obtain?

• A. Percussion of the abdomen.
• B. Blood glucose level.
• C. Serum electrolytes.
• D. Level of consciousness.

Correct answer: D

Rationale: The correct answer is D: Level of consciousness. Lactulose is used to reduce ammonia levels in hepatic encephalopathy, which can affect brain function. Therefore, monitoring the client's level of consciousness is crucial to evaluate the therapeutic response. Changes in consciousness can indicate the effectiveness of lactulose in reducing ammonia levels. Choices A, B, and C are incorrect because while they are important assessments in various conditions, they are not specifically related to evaluating the therapeutic response of lactulose in hepatic encephalopathy.

4. After an older client receives treatment for drug toxicity, the healthcare provider prescribes a 24-hour creatinine clearance test. Before starting the urine collection, the nurse noted that the client's serum creatinine was 0.3 mg/dL. Which action should the nurse implement?

• A. Check the client's urine output hourly
• B. Instruct the client to increase fluid intake
• C. Notify the healthcare provider of the results
• D. Start the 24-hour urine collection

Correct answer: C

Rationale: A serum creatinine level of 0.3 mg/dL is abnormally low, indicating potential issues with the interpretation of the creatinine clearance test. It is crucial for the nurse to notify the healthcare provider of this result before proceeding with the 24-hour urine collection. Checking urine output, instructing the client to increase fluid intake, or starting the urine collection without consulting the healthcare provider could lead to incorrect test results and misinterpretation of the client's renal function.

5. A client with COPD and a history of emphysema presents with increasing shortness of breath. What action should the nurse implement first?

• A. Notify the healthcare provider of the client's distress.
• B. Auscultate the client's lung sounds and oxygen saturation.
• C. Determine if the client is experiencing anxiety.
• D. Assess the oxygen delivery system.

Correct answer: B

Rationale: The correct action for the nurse to implement first is to auscultate the client's lung sounds and oxygen saturation. This helps in assessing the respiratory status of the client, which is crucial in managing COPD and emphysema exacerbations. Checking for any abnormalities in lung sounds and monitoring oxygen saturation levels can provide important information for immediate intervention. Option A is not the first action to take in this situation as directly assessing the client's respiratory status is more immediate. Option C, determining if the client is experiencing anxiety, is important but should come after assessing the physical respiratory status. Option D, assessing the oxygen delivery system, is also essential but should follow the direct assessment of the client's respiratory status.

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