a nurse is reviewing the ABG results of a client who the
provider suspects has metabolic acidosis. what would the
nurse expect to see
pH below 7.35
a pt is experiencing SOB, fatigue, JVD, the nurse
auscultates a third heart sound (S3), what should the
nurse anticipate as the cause of these s/s
HF
a nurse is administering potassium chloride elixer 40mEq
divided into 2 equal doses every 12 hours, available is 6.7
mEq/5mL. how many mL should the nurse administer per
dose?
30mL
a nurse is caring for a pt in the ED who was just admitted
with chest pain, possible acute coronary syndrome. what
should the nurse do first?
administer sublingual nitroglycerin
(treat chest pain to reduce cardiac tissue damage)
a nurse is caring for pt who is experiencing ventricular
tachycardia with a pulse, the RRT is at the bedside. what
electrical intervention should be used to correct this
dysrhythmia?
synchronized cardioversion
(tx for afib, SVT, and v tach with a pulse)
,a nurse is caring for an adult pt who is experiencing
delayed wound healing, which of the following
interventions should the nurse take?
monitor serum albumin levels and notify provider if below
3.5g/dL
(lack of protein increases the risk for a delay in wound
healing and infection)
a nurse is teaching a client who has pre-dialysis ESKD
about diet, what should be included?
reduce intake of foods high in potassium
(potassium clearance is impaired in ESKD)
a nurse is caring for a client who has T1DM, the nurse
misread the client's morning BG level as 210mg/dL,
instead of 120mg/dL and administered the insulin dose
appropriate for a reading over 200mg/dL before the
client's breakfast, what action is the nurse's priority?
monitor the client for hypoglycemia
a nurse is planning care for a pt who has a new diagnosis
of DI, which of the following interventions should the
nurse include in the plan of care?
check urine specific gravity
a nurse is caring for a pt admitted with wheezing and
coughing due to an allergic reaction to a newly prescribed
medication, what medication should be administered
first?
, albuterol 3mL via nebulizer
a nurse is caring for a female client in the ED who reports
SOB and pain in the lung area, she states that she started
taking BC pills 3 weeks ago and that she smokes, her
heart rate is 110/min, RR 40/min, and BP 140/80, her
ABGs are pH 7.50, PaCO2 29, PaO2 60, HCO3 20, SaO2
86%, what is the priority of nursing interventions
administer oxygen via face mask
a nurse is caring for a pt following repair of a fracture,
what finding should alert the nurse that the pt is
experiencing compartment syndrome?
unrelieved pain, pallor, pulselessness, numbness, pins
and needles sensation, swelling, tightness of the effected
extremity
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a nurse is administering a tap water enema to a pt who is
constipated, during the administration of the enema, the
client states he is having abdominal cramps, what action
should the nurse take to relieve the client's comfort
lower the height of the solution container
a pt is diagnosed with left homonymous hemianopsia
following a stroke, what action should the nurse take?
place the clients bedside table on the right side of the
bed
