Blood/ABG
The nurse is monitoring a blood transfusion for a client with anemia. Five minutes after the transfusion begins, the client reports feeling short of breath and itchy. Which action should the nurse take?
a. Reassure the client that the feelings are associated with anxiety and will pass.
b. Confirm the shortness of breath by listening to the client’s lungs
c. Stop the transfusion and notify the health care provider.
d. Increase the rate of infusion to restore blood volume more quickly.
Answer:
Stop the transfusion and notify the health care provider.
Suspicious for beginning reaction to blood
An older adult client with hypokalemia is being discharged to the home of a caregiver. Which information should the nurse include in the family teaching?
Include more canned vegetables in the diet
Include more cheese in the diet.
Include more bread in the diet.
Include more bananas in the diet.
Answer:
Include more bananas in the diet
A nurse attempts to relieve the pain of a client by using cutaneous stimulation. Which of the following describes usage of this technique?
a. A nurse guides a client to use imagery.
b. A nurse uses deep-breathing exercises to distract a client from their pain.
c. A nurse applies intermittent heat and cold to a client's leg.
d. A nurse distracts the client by playing their favorite music.
Answer:
A nurse applies intermittent heat and cold to a client's leg.
Heat and cold alters nerve conduction and reduces muscle spasm or inflammation.
The nurse is preparing to administer fluid replacement to a client. Which action should the nurse take first?
Check for the availability of an IV pump.
Verify the prescription for type of solution and amount of infusion.
Calculate the number of drops per minute.
Regulate the rate of administration.
Answer:
Verify the prescription for type of solution and amount of infusion.
The nurse is caring for a 65-year-old client whose spouse died 4 months ago. The client tells the nurse about not doing well and that no one will talk with them about their spouse. Which is the nurse's priority intervention for this client?
a. Refer the client to a consciousness-raising group
b. Refer the client to an encounter group
c. Refer the client to a support group
d. Refer the client to a religious support group
Answer:
Refer the client to a support group
A client scheduled for surgery has arranged for an autologous transfusion. What type of blood transfusion is this?
The client's family members have been donors.
The client donates their own blood.
The client's blood has been rendered sterile.
The client will only need fluids, not blood
Answer:
The client donates their own blood.
The nurse is educating a client with hypokalemia on why it is important to maintain potassium balance. Which does the nurse include in the teaching?
a. Visual acuity
b. Neurologic function
c. Cardiac function
d. skeletal integrity
Answer:
Cardiac function
The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain?
a. A client suspected to have a perforated peptic ulcer
b. A client who has a sprained ankle
c. A client with chest pain
d. A client who has appendicitis
Answer:
A client who has a sprained ankle
Somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves
The nurse's morning assessment of a client who has a fluid overload with evidence of 2+ pitting edema in the client's ankles and feet bilaterally. Which action should the nurse take to help alleviate the edema?
Elevate the legs
Deeply massage the legs
Direct the client to remain on bed rest
Request additional salt to be added to the diet
Answer:
Elevate the legs
The nurse at the student health center is seeing a group of nursing students who are interested in reducing their stress level. The nurse identifies guided imagery as an appropriate intervention. What does guided imagery involve?
a. The use of progressive tensing and relaxing of muscles to release tension in each muscle group
b. Using positive self-image to increase and intensify physical workouts in the gym, which decreases stress
c. The mindful use of a word, phrase, or visual image that allows oneself to be distracted and temporarily escape from stressful situations
d. The use of music and humor to create a calm and relaxed demeanor, which allows escape from stressful situations
Answer:
The mindful use of a word, phrase, or visual image that allows oneself to be distracted and temporarily escape from stressful situations
A client receiving a blood transfusion begins to show shortness of breath, crackles in the lung bases, and increased blood pressure. Which transfusion reaction does the nurse suspect?
Assess oxygen levels.
Assess for circulatory overload
Assess for visible rash.
Assess vital signs.
Answer:
Assess for circulatory overload
The nurse is caring for a client with “hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy.” What is an appropriate expected outcome?
a. Bowel motility will be restored within 24 hours after beginning supplemental K+.
b. ECG will show no cardiac arrythmias within 48 hours after removing K+-rich foods from diet.
c. ECG will show no cardiac arrythmias within 24 hours after beginning supplemental K+.
d. Bowel motility will be restored within 24 hours after eliminating K+-rich foods from the diet.
Answer:
ECG will show no cardiac arrythmias within 48 hours after removing K+-rich foods from diet.
A nurse attempts to arouse a postoperative client and finds them frequently drowsy and drifting off during conversation. What would be the sedation score for this client?
a. 1
b. 2
c. 3
d. 4
Answer:
The sedation score for this client is 3.
A client with dehydration is being administered IV fluids. During rounds, the nurse noticed that the skin immediately surrounding the IV site was reddish in color and showing signs of inflammation. The nurse recognizes that what phenomenon is likely responsible?
a. Phlebitis
b. Thrombus formation
c. Pulmonary embolus
d. Air embolism
Answer:
Phlebitis
ABG Results:
pH = 7.37
PaCO₂ = 55 mmHg
HCO₃⁻ = 32 mEq/L
Which interpretation is correct?
a. Uncompensated respiratory acidosis
b. Partially compensated metabolic alkalosis
c. Fully compensated respiratory acidosis
d. Uncompensated metabolic acidosis
Answer:
Fully compensated respiratory acidosis
Rationale:
pH is normal (but slightly on the acid side)
PaCO₂ high → respiratory acidosis
HCO₃⁻ high → renal compensation
→ Fully compensated respiratory acidosis
What are some common causes of respiratory alkalosis?
a. Hyperventilation
b. Hypoxemia
c. Sepsis
d. Normal saline
Answer:
a: blowing off too much co2
b: too little oxygen in the tissues
c: systemic process which consumes more O₂ and produce more CO₂, thus resulting in hyperventilation
A group of nursing students is reviewing information about body fluid and locations. The students demonstrate understanding of the material when they identify which of the following as a function of intracellular fluid?
Maintenance of cell size
Maintenance of blood volume
Transportation of nutrients
Removal of waste
Answer:
Maintenance of cell size
The nurse is using a pillow to help splint the postsurgical client's abdomen to manage what type of pain?
a. Splanchnic
b. Deep somatic
c. Neuropathic
d. Superficial
Answer:
Deep somatic
(Deep somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, muscles and nerves).
A nurse is inspecting the IV site of a client and notices that the site is swollen, red, warm to the touch, and painful. Which action by the nurse is appropriate?
a. Discontinue the IV and relocate it to another spot.
b. Call the health care provider for anti-inflammatory drugs
c. Cleanse the site with chlorhexidine solution
d. Cleanse the site with alcohol and apply transparent dressing
Answer:
Discontinue the IV and relocate it to another spot.
ABG results:
pH = 7.50
PaCO₂ = 48 mmHg
HCO₃⁻ = 32 mEq/L
What condition does this represent?
A. Partially compensated metabolic alkalosis
B. Uncompensated metabolic alkalosis
C. Fully compensated respiratory alkalosis
D. Uncompensated respiratory acidosis
Answer:
a. Partially compensated metabolic alkalosis
Rationale:
pH > 7.45 → alkalosis
HCO₃⁻ > 26 → metabolic cause
PaCO₂ > 45 → respiratory system trying to compensate
→ Partial compensation because pH still abnormal
What are some causes of hypoventilation? (select all that apply)
a. Chronic obstructive pulmonary disease (COPD)
b. Airway obstruction
c. Respiratory depression
d. Sleep apnea
Answers: all
a. Chronic obstructive pulmonary disease (COPD) — air trapping and ineffective ventilation
b. Airway obstruction for example asthma causing severe bronchoconstriction
c. Respiratory depression such as opioid overdose
d. Periods of breathing cessation during sleep
The nurse is preparing to administer fluid replacement to a client. Which action related to intravenous therapy is outside the nurse's usual scope of practice?
a. Preparing a prescribed fluid for administration
b. Choosing to change a client's hypotonic solution to an isotonic solution
c. Performing venipuncture as ordered
d. Regulating the rate of administration
Answer:
Choosing to change a client's hypotonic solution to an isotonic solution
A nurse is administering prescribed medicine to a client who experienced acute pain in the lower back after a motor vehicle accident. The client tells the nurse that compared to the previous week, their pain had reduced considerably. Which phase of pain is the client experiencing?
a. Transduction
b. Transmission
c. Perception
d. Modulation
Answer:
Modulation
(The client is in the modulation phase of pain, during which the brain interacts with the spinal nerves in a downward fashion to subsequently alter the pain experience).
While obtaining a health history from a client, which question is most appropriate for the nurse to ask the client to assess fluid balance?
a. “How much do you typically urinate during the day?”
b. “How often do you usually have a bowel movement?”
c. “How often do you experience leg cramps?
d. “How much coffee do you drink during a typical day?”
Answer:
“How much do you typically urinate during the day?”
What are some common causes of metabolic alkalosis include? (select all that apply)
a. Vomiting
b. Nasogastric suctioning
c. Excess bicarbonate intake
d. Intravenous dextrose
Answer:
a, b, c