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A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?

Prepare to administer a sedative.

Prepare for mechanical ventilation.

Massage the calf area for tenderness.

Assess for indications of pulmonary embolism.

None

Answer and Explanation

The Correct Answer is D

The correct answer is d. Assess for indications of pulmonary embolism.

Choice A rationale:

Administering a sedative is not appropriate as the priority intervention. Sedatives can depress respiratory function, which is already compromised in this patient.

Choice B rationale:

Preparing for mechanical ventilation might be necessary if the patient’s condition worsens, but it is not the immediate priority. The priority is to identify the underlying cause of the symptoms.

Choice C rationale:

Massaging the calf area for tenderness is not relevant in this context. While calf tenderness can be a sign of deep vein thrombosis (DVT), which can lead to pulmonary embolism, the immediate priority is to assess for pulmonary embolism directly.

Choice D rationale:

Assessing for indications of pulmonary embolism is the priority because the patient’s symptoms (shortness of breath, chest pain, recent use of birth control pills, smoking history, and abnormal ABG values) strongly suggest a pulmonary embolism. Early identification and treatment are crucial to prevent further complications.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","B","D"]

Explanation

The correct answer is choices A, B, and D. Here are the rationales for each choice:

Choice A rationale:

Sweet potatoes are an excellent source of potassium. One medium sweet potato contains about 542 mg of potassium, making it a great option for a high-potassium diet.

Choice B rationale:

Bananas are well-known for their high potassium content. A medium banana provides approximately 451 mg of potassium, which is beneficial for maintaining proper muscle and nerve function.

Choice C rationale:

Grapes are not particularly high in potassium compared to other fruits. They contain some potassium, but not enough to be considered a significant source for a high-potassium diet.

Choice D rationale:

Watermelon is a good source of potassium. Two wedges of watermelon contain about 640 mg of potassium, making it a suitable choice for increasing potassium intake.

A. Encourage the patient to breathe in and out slowly into a paper bag. B. Immediately administer oxygen via a mask and monitor oxygen saturation. C. Anticipate the administration of intravenous sodium bicarbonate. D. Prepare to start an intravenous fluid bolus using isotonic fluids.

Correct Answer is A

Explanation

The correct answer is choice A: Encourage the patient to breathe in and out slowly into a paper bag.

Choice A rationale:The patient’s arterial blood gas (ABG) results indicate respiratory alkalosis, as evidenced by the elevated pH (7.48) and decreased PaCO2 (25 mm Hg). Respiratory alkalosis often results from hyperventilation, which can occur due to anxiety. Breathing into a paper bag helps to increase CO2 levels in the blood, thereby correcting the alkalosis.

Choice B rationale:Administering oxygen is not appropriate in this scenario because the patient’s PaO2 is already elevated (110 mm Hg), indicating that oxygenation is not the issue. Providing additional oxygen would not address the underlying problem of hyperventilation and respiratory alkalosis.

Choice C rationale:Intravenous sodium bicarbonate is used to treat metabolic acidosis, not respiratory alkalosis. In this case, the patient’s HCO3 is within the normal range (24 mEq/L), indicating that there is no metabolic acidosis present.

Choice D rationale:Starting an intravenous fluid bolus with isotonic fluids is not indicated for correcting respiratory alkalosis. This intervention is more appropriate for patients experiencing hypovolemia or dehydration, which is not suggested by the patient’s ABG results.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to teach a client about a high-potassium diet. Which of the following foods should the nurse instruct the client to eat? (Select all that apply.).

Correct Answer is ["A","B","D"]

Explanation

The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. Which intervention should the nurse expect to be prescribed to correct this problem?

Correct Answer is A

Explanation

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?

A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient?

The patient who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this patient?

A nurse is teaching a client who is on a low-sodium diet. Which of the following instructions should the nurse include? (Select All that Apply.).

A nurse is reviewing the laboratory results of a client who is dehydrated. Which of the following BUN lab values should the nurse report to the provider?

A nurse is reviewing the medical record of a client who has a potassium level of 3.0 mEq/L. Which of the following findings should the nurse recognize as a potential causative factor?

A nurse is caring for a client who is receiving an IV infusion of dextrose 10% in water. The nurse should monitor the client for which of the following adverse effects?