NCLEX Prep

ABGs

Step 1: Look at pH. If less than 7.35, identify as acidosis. If greater than 7.45, identify as alkalosis. QEBP​​​​​​​ Step 2: Look at PaCO2 and HCO3- simultaneously. Determine which is in the expected reference range. Conclude that the other is the indicator of imbalance. Identify PaCO2 less than 35 or greater than 45 mm Hg as respiratory in origin. Identify HCO3- less than 22 or greater than 26 mEq/L as metabolic in origin. Step 3: Combine diagnoses of Steps 1 and 2 to name the type of imbalance. Step 4: Evaluate the PaO2 and SaO2. If the results are less than the expected reference range, the client is hypoxic. Step 5: Determine compensation as follows. Uncompensated: The pH is outside the expected reference range, and either the HCO3- or the PaCO2 is outside the expected reference range. Partially compensated: The pH, HCO3-, and PaCO2 are outside the expected reference range. Fully compensated: The pH is within the expected reference range, but the PaCO2 and HCO3- are both outside the expected reference range. Looking at the pH will provide a clue as to which system initiated the problem, respiratory or metabolic. If the pH is less than 7.40, think "acidosis," and determine which system has the acidosis value. If the pH is greater than 7.40, think "alkalosis," and determine which system has the alkalosis value.

A client is sitting up in a chair with a vest restraint. What action should the nurse take to minimize the risk for pressure injuries?

Teach the client to shift their weight in the chair every 15 minutes A client in a vest restraint is at risk for pressure injuries. If the client is sitting, the nurse should encourage the client to shift their weight every 15 minutes. It is dangerous to crisscross the straps behind the client's back as it may cause strangulation. Removing clothing from beneath the vest will increase the risk for a pressure injury. Changing the vest every 2 to 4 hours is not necessary or appropriate to decrease the risk for pressure injuries.

Parents of a preschool-age child ask the nurse about nutrition. Which statement about a preschooler's nutritional requirements is accurate?

The quality of food that a preschooler consumes is more important than the quantity. Stating that food quality is more important than quantity is most accurate because a high caloric intake may include many empty calories. The preschooler's caloric requirement is slightly lower than the toddler's. Overall, however, the preschooler's nutritional requirements are similar to a toddler's. The preschooler requires 1.5 g/kg of protein daily, satisfied by two meat servings, three milk servings, four bread servings, and four fruit and vegetable servings.

A primipara calls the birthing unit 3 days after a vaginal birth. The client tells the nurse that they are bottle-feeding and their breasts are swollen and painful. Which instructions would be appropriate?

Use ice packs for 20 minutes every 3 to 4 hours. Explanation: Ice packs cause vasoconstriction and can provide temporary relief of breast engorgement for the bottle-feeding birth parent.Breast engorgement is transitory and usually disappears within a few days. A tight breast binder is not recommended because it can worsen the engorgement and restrict blood flow. A supportive bra should be worn at all times by both bottle-feeding and breastfeeding parents.Taking a warm shower may help relieve some of the discomfort of the breast engorgement.

During a physical, the nurse assesses drug and alcohol use in a client with several screening tools, including the CAGE (Cut, Annoyed, Guilty, Eye) tool. The client answered "yes" to three questions in the CAGE tool. What kind of education should the nurse provide to the client?

health benefits of cutting down on alcohol use Explanation: The CAGE tool is a series of four questions about alcohol use. A client who states "yes" to two or more of the questions may have a problem with alcohol. If the client screens positive, the nurse should assess if the client is ready to change and provide appropriate education. The CAGE tool does not measure withdrawal symptoms, which may necessitate seizure precautions or medication such as a benzodiazepine and education about those effects. The CAGE tool measures alcohol use, not drug use, so it would not be appropriate to ask the client about medications they take to provide education.

A nurse is planning care for an adolescent client who is 12 weeks' gestation. The nurse will monitor this client closely for the development of which complication during this stage of the pregnancy?

iron-deficiency anemia Explanation: Adolescent pregnancies have a high risk for obstetric complications such as preterm labor and births, low birthweight infants, iron-deficiency anemia, sexually transmitted infections, poor maternal weight gain, preeclampsia, poor eating habits, nutrition, and postpartum depression. Menstrual losses often lead to iron-deficiency anemia in clients during their reproductive years meaning anemia can be an existing issue at the time of conception. In the case of an adolescent client, the client is also still developing, which consumes additional iron stores compared to an adult client. The consumption of iron during pregnancy for fetal growth and an increased blood supply compounds the anemia even further. At 12 weeks' gestation, preeclampsia or gestational hypertension is unlikely as this develops usually after 20 weeks. The client could be at risk for depression but not postpartum depression while still in the antepartum stage. Younger clients are not at increased risk for gestational diabetes and this complication usually occurs after the 24th week of pregnancy which is why screening is done between 24 and 28 weeks.

A client has a coxsackie B (viral) or trypanosomal (parasite) infection. The nurse should further assess the client for which health problem?

myocarditis Why? Intracellular microorganisms, such as viruses and parasites, invade the myocardium to survive. These microorganisms damage the vital organelles and cause cell death in the myocardium. The myocardium becomes weak, leading to heart failure; then T lymphocytes invade the myocardium in response to the viral infection.

Over the past few weeks, a client in a long-term care facility has become increasingly unsteady. The nurses are worried that the client will climb out of bed and fall. Which measure does not comply with a least restraint policy?

raising all side rails while the client is in bed Why? Raising all side rails on the bed would be a restraint and may increase the client's risk of a falling if the client climbs out of bed. All the other options would comply with a least restraint policy.

When planning care for a client who has ingested phencyclidine (PCP), the nurse's highest priority should be meeting the client's:

safety needs. Explanation: The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as those of the staff. Drug effects are unpredictable and prolonged, and the client may easily become aggressive and physically violent. After safety needs have been met, the client's physical, psychosocial, and medical needs may be addressed.

The nurse is caring for a client with suicidal ideation on an inpatient unit. Which activity should the nurse recommend when the client has thoughts of suicide?

talking with the nurse Talking with a staff member when suicidal thoughts occur is an important part of contracting for safety. The nurse or another staff member can then assess whether the client will act on the thoughts and assist the client with methods of coping when suicidal ideation occurs. Writing in a journal, engaging in physical activity, or playing games with others does not allow the client to verbalize suicidal thoughts to the nurse.

When assessing the chest of a 4-month-old infant, the nurse identifies the ratio of the anteroposterior-to-lateral diameter as 1:1. What action should the nurse take next?

No action is needed; this is a normal finding. No action is needed by the nurse because in an infant, the anteroposterior diameter is normally equal that of the lateral diameter (a ratio of 1:1). As the infant reaches toddlerhood, the anteroposterior diameter becomes less than the lateral diameter.

The nurse manager in surgical services hears a fire alarm from one of the operating rooms. The staff respond quickly to make sure the client and staff are safe. What should the manager do first?

Perform a root cause analysis to determine the cause of the fire. When a sentinel event occurs, like a fire in the operating room, the nurse manager should perform a root cause analysis to determine the cause. Other actions, like providing education, reassigning or disciplining staff, or removing devices from the operating room should occur only after the cause is known.

A nurse is caring for a 7-year-old client with Down syndrome. The nurse uses what approach to best implement appropriate care for the client?

Plan interventions according to developmental age. Explanation: Nursing care should be planned at the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mild to severe cognitive impairment, each child should be individually assessed. Depending on the client's developmental age, the nurse may provide some control over care, but this is part of considering the child's developmental age when planning care.

A high school student is brought to the nurse by the chemistry instructor after a classmate accidentally spilled a toxic chemical on the student's hands. Which action should the school nurse prioritize in this situation?

Run water at low pressure over the hands to remove the chemical. Explanation: The nurse should use copious amounts of lukewarm water at a low pressure to dilute the chemical and avoid driving the chemical deeper into the tissues. Ice or cold water would not be used because these could cause hypothermia. The chemical should be removed, not deactivated by a neutralizing agent.