Acid-Base Balance
When reviewing arterial blood gases, what is the nurse’s first step in determining whether an acid–base imbalance exists?
pH to determine whether the client is acidemic or alkalemic, establishing the primary problem before analyzing PaCO₂ and HCO₃⁻.
Which assessment findings suggest possible internal bleeding in a client with impaired clotting?
Hematuria, melena, hematemesis, decreased hemoglobin/hematocrit, hypotension, and altered mental status. Petechiae, ecchymosis, prolonged bleeding from minor injuries, bleeding gums, epistaxis, and blood in urine or stool.
A nurse is assessing an older adult who was alert and oriented yesterday. Which findings are most concerning for acute cognitive impairment and require immediate follow-up?
Fluctuating level of consciousness, disorganized thinking, inattention, altered sleep–wake cycle, and difficulty following simple commands.
A nurse is caring for a postoperative client who states, “I’m okay,” but is grimacing, guarding the incision, and has an elevated heart rate. What is the most appropriate nursing assessment?
Comprehensive pain assessment using a validated pain scale and behavioral indicators, including location, quality, intensity/severity, timing, setting, associated findings, aggravating factors, alleviating factors. BP, HR, and RR can temporarily increase with acute pain.
What are potential complications of bowel and bladder elimination?
Skin irritation, fungal infection, and/or skin breakdown; depression and anxiety; fluid and electrolyte imbalances (dehydration and hypokalemia); retention; urinary tract infection due to urinary stasis; bowel impaction; diarrhea; intestinal obstruction.
ABG results show pH 7.49, PaCO₂ 29 mmHg, HCO₃⁻ 35 mEq/L. Explain the imbalance and the nursing significance.
Metabolic alkalosis (elevated pH and an elevated bicarbonate level, along with normal oxygen and carbon dioxide levels). Caused from increase of base components or loss of acid. Interventions à Administer fluids as prescribed. Administer electrolyte replacement if prescribed. Initiate fall and safety precautions. Stop causative agents.
What teaching should the nurse prioritize for a client at risk for excessive clotting?
Encourage adequate hydration, frequent ambulation, avoidance of leg crossing, smoking cessation, and reporting signs of DVT.
A hospitalized client on prolonged bed rest in a private room appears withdrawn, disoriented, and slow to respond. Which nursing action best addresses the likely cause of these changes?
Increase cognitive and sensory stimulation by providing clocks, calendars, regular social interaction, increase touch, communicate frequently with client, and exposure to normal day–night cues. Encourage the client to engage in activities that require mental engagement (crossword puzzles, whistling, reciting).
A client with chronic low back pain prefers to avoid additional medication. Which nursing interventions are appropriate to promote comfort?
Apply heat/cold therapy, cognitive-behavioral measures, Cutaneous (skin) stimulation; distraction; imagery; Acupuncture and acupressure; Reduction of pain stimuli in the environment; Elevation of extremities; Progressive relaxation.
What nursing strategies best manage urinary incontinence?
Scheduled frequent toileting, skin protection, Kegel exercises, restrict fluids 1–2 hours before bedtime, and individualized bladder training.
How does the body attempt to compensate for chronic respiratory acidosis, and how does this affect nursing interpretation of labs?
The kidneys retain bicarbonate and excrete hydrogen ions, resulting in elevated HCO₃⁻ and near-normal pH. Nurses must recognize compensation rather than assuming normal values indicate stability.
Which nursing interventions are appropriate when instituting bleeding precautions for a client with thrombocytopenia?
Use a soft toothbrush, avoid IM injections and rectal procedures, apply prolonged pressure to venipuncture sites, avoid aspirin/NSAIDs, and monitor for occult bleeding.
A client with a traumatic brain injury becomes restless, irritable, and unable to focus when multiple staff members speak at once. Which nursing intervention is most appropriate?
Reduce environmental stimuli by limiting visitors, speaking one person at a time, and maintaining a quiet, structured environment. Reduce lights and noises. Offer the client earplugs and dark glasses if needed. Limit visitors. Assist the client with stress reduction. Schedule sleep to minimize interruptions. Provide orientation cues (calendars, clocks).
Before a client begins herbal supplements for pain management, what is the nurse’s responsibility in this situation?
Assess current medications and risk for drug–herb interactions; Be receptive to learning about clients’ alternative health beliefs and practices; evaluate safety of herbs; provide reliable information and determine interactions; incorporate in plan of care.
A postoperative client has not voided 8 hours after surgery. What is the nurse’s initial intervention?
Assess bladder distention and intake/output.
What conditions are common causes of respiratory acidosis?
Respiratory depression: Anesthetics, Drugs (especially opioids), Electrolyte imbalance; Inadequate chest expansion: Muscle weakness, Airway obstruction, Alveolar-capillary block
How does the nurse evaluate whether anticoagulant therapy is effective and safe?
By monitoring coagulation labs, assessing for signs of bleeding or thrombosis, and correlating findings with the client’s clinical status. Labs INR: 0.8–1.2 (therapeutic range for warfarin typically 2.0–3.0); Prothrombin Time (PT): 11–13.5 seconds; Activated Partial Thromboplastin Time (aPTT): 25–35 seconds (therapeutic range for heparin typically 60–80 seconds); Platelet count: 150,000–400,000/µL; Hemoglobin (Hgb): Females: 12–16 g/dL, males: 14–18 g/dL; Hematocrit (Hct): Females: 36–46%, Males: 41–53%
How should the nurse differentiate delirium from dementia?
Delirium has an acute onset with a fluctuating course and is usually reversible when the underlying cause is treated, whereas dementia develops gradually, is progressive, and is generally irreversible. The etiologies, nursing priorities, and urgency of intervention differ significantly.
A nurse is developing a comfort plan for a client with metastatic cancer experiencing pain, nausea, and anxiety. Which approach best supports holistic comfort?
Combine pharmacologic therapy with nonpharmacologic strategies such as relaxation techniques, positioning, spiritual support, and environmental modification.
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
Use aseptic technique when inserting catheters. Prevent obstruction and backflow of urine through catheter, drainage tubing, and drainage bag. Keep the urinary drainage bag below the level of the bladder. Provide perineal hygiene routinely and after soiling. Assess ongoing need for indwelling urinary catheter daily. Keep the urinary drainage system sterile and closed. Drain the urinary drainage bag before it is half full.
Prioritize nursing actions for a client with worsening respiratory alkalosis.
Have patient breathe into a paper bag if hyperventilation (often due to anxiety) is the causative agent. Provide calm reassurance and emotional support as needed if hyperventilation is the causative agent. Provide supplemental oxygen as needed. Monitor for drop in bicarb.
A client’s lower extremity becomes pale, cool, and painful with absent distal pulses. What is the nurse’s priority action?
Notify the provider or Rapid Response Team immediately and keep the extremity flat (do not elevate).
Which nursing intervention best supports cognitive function in a client with early-stage dementia?
Provide frequent reorientation, involve the client in simple decision-making, and encourage participation in familiar activities. Speak to client using a calm voice. Remove contributing factors causing the client’s confusion. Maintain a sleeping schedule and monitor for irregular sleeping patterns. Keep a structured environment and introduce change gradually (client’s daily routine or a room change). Be consistent and repetitive. Use short directions when explaining an activity or care the client needs, such as a bath. Reduce agitation. (Use calm, redirecting statements. Provide a diversion. Use music therapy to calm or distract.)
Which intervention is most effective in promoting comfort for a client at end of life?
Low-flow oxygen, upright positioning, medication administration as prescribed, reposition, suction, respect autonomy, caring touch, therapeutic communication, encourage family care, encourage independence as possible, make presence known, provide privacy.
How should nursing interventions differ for a client with constipation versus one with diarrhea?
Constipation: encourage fluid, fiber, activity, and possibly stool softeners. Enemas are a last resort for stimulating defecation. Diarrhea: prevent dehydration, encourage fluid intake, monitor electrolytes, implement infection control, and identify underlying causes. Protect the perineal and buttock area with a topical barrier agent to prevent skin irritation and excoriation, especially for patients who are incontinent. Instruct client to avoid bowel irritants, such as caffeinated beverages and alcohol.