Nclex- Acid-Base Balance/ Diagnostic test
The nurse informs a client that a Papanicolaou smear will be done at the next scheduled clinic visit, and the nurse provides instructions to the client regarding preparation for this test. Which statement by the client indicates an understanding of the procedure?
"If I have my period at the time of my next scheduled visit, I will not be able to have the test done.":
The nurse determines that which clients are at high risk for metabolic acidosis? Select all that apply.
ANS: 1. Clients with diabetes 2. Clients with kidney failure 3. Clients with malnourishment
The nurse is preparing a client for the administration of a tuberculin skin test. The nurse determines that which body areas are appropriate for intradermal injections? Select all that apply.
ANS: 1. Inner aspect of the forearm 2.Dorsal aspect of the upper arm 3.Away from heavy pigmentation
A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. The nurse would tell the client which information about the test?
ANS: The dye injected may cause a warm, flushing sensation.
The nurse is reinforcing instructions about the procedure to a client who is to have a gallium scan. The nurse would include which item as part of the instructions?
ANS: The gallium will be injected intravenously 2 to 3 hours before the procedure.
A client has just undergone endoscopy. Which is the essential postprocedure nursing intervention?
ANS:Check the gag reflex before giving oral foods or fluids.
Abdominal ultrasonography is prescribed for a client who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement?
ANS: "You will be positioned on your back and turned slightly to one side with your head elevated."
The nurse is reinforcing postprocedure teaching after a client underwent an upper gastrointestinal (GI) series. The nurse reminds the client that the stools will remain white for approximately how long?
ANS: 1 to 2 days
A client who has undergone barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions when the client makes which statement?
ANS: "I will be sure the barium passes and watch for my stools to return to normal."
The nurse reinforces what information to a client who is scheduled for an electromyogram (EMG)?
ANS: Electrodes will be inserted into the skeletal muscles.
n adult female client has a hemoglobin level of 10.8 g/dL (108 g/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?
ANS: Iron deficiency anemia
The nurse is planning to administer an oral glucose tolerance test (OGTT) to a client to rule out or confirm diabetes mellitus. The nurse knows that the client needs more information when the client makes which statements? Select all that apply.
ANS: 1. "I can at least drink fluids during the test." 2. " I have 30 minutes to drink the glucose load."
A client has been diagnosed with metabolic alkalosis. Which laboratory values are most important for the nurse to monitor for this client? Select all that apply.
ANS: 1. Serum electrolytes 2. Arterial blood gases (ABGs)
A client is scheduled for a myelogram, and the nurse reinforces a list of instructions to the client regarding preparation for the procedure. Which instructions would the nurse include in the list? Select all that apply.
ANS: 1.Jewelry will need to be removed. 2.An informed consent will need to be signed. 3. Nonalcoholic fluid intake should be increased after the procedure.
The nurse has just confirmed that a client has been scheduled for a mammogram for the following week. The nurse reinforces that the client would take which actions? Select all that apply.
ANS: 1. Avoid applying skin lotion on the day of the test. 2.Remove any necklaces before presenting for the procedure.
A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse trying to enhance the client's respiratory status would avoid performing which actions? Select all that apply.
ANS: 1. Increasing the liter flow to 5 L per nasal cannula 2. Encouraging the client to breathe slowly and shallowly
The nurse is observing a nursing student preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which actions indicate the need for further teaching regarding collecting this specimen? Select all that apply.
ANS: 1. The student asks the client to tilt the head forward and to open the mouth. 2. The student informs the client that the test will help identify microorganisms. 3.The student places the collection swab initially at the back of the client's tongue.
The nurse is preparing a client scheduled for a bone marrow aspiration, and the client asks the nurse whether the procedure will be painful. The nurse would make which response to the client?
ANS: "A local anesthetic will be given and will decrease the discomfort."
The nurse reinforces instructions to a client who is to return to the primary health care provider's office in 1 week for a patch test to identify the allergen causing the dermatitis. The nurse provides which instruction to the client?
ANS: "Discontinue the prescribed antihistamine 2 days before the test."
A client being seen in a primary health care provider's office has just been scheduled for a barium swallow the next day. The nurse writes down which instructions for the client to follow before the test?
ANS: "Do not eat or drink after midnight tonight."
The nurse has reinforced instructions to a client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that there is a need for further teaching if the client makes which statement?
ANS: "I hope the incision from the test will heal quickly."
A 24-hour urine specimen for creatinine and electrolytes has been prescribed for a hospitalized client to evaluate kidney function. The nurse explains the procedure to the client. The client voids at 0900, and the urine is discarded. The client voids at 1200, and the urine is measured and placed in the collection container. At which time the next day would the 24-hour urine collection be complete? Fill in the blank with the correct military time.
ANS: 0900
The nurse is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 30 mm Hg (30 mm Hg), and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value would the nurse expect to note?
ANS: A potassium level of 3.0 mEq/L
A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which medication that would be prescribed to treat this acid-base disorder?
ANS: Acetazolamide
A lethargic, pale child is brought to the primary health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The primary health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which laboratory test would rule out a past streptococcal infection in the child?
ANS: Antistreptolysin titer
A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on which understanding?
ANS: Discomfort may occur with needle insertion, and there is minimal exposure to radiation.
A client brought to the emergency department states that he has accidentally been taking two times his prescribed dose of warfarin for the past week. After noting that the client has no evidence of obvious bleeding, the nurse plans to assist the registered nurse with which action?
ANS: Drawing a sample for prothrombin time (PT) and international normalized ratio (INR)
A client has had a bone scan procedure. The nurse determines that the client understands the elements of follow-up care if the client states which postprocedural care?
ANS: Drink plenty of water for a day or two following the procedure.
The licensed practical nurse (LPN) is assisting in the care of a client who overdosed on acetylsalicylic acid 24 hours ago. The LPN would report to the registered nurse (RN) which findings associated with an anticipated acid-base disturbance?
ANS: Drowsiness, headache, and tachypnea
A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action would the nurse plan to take?
ANS: Encourage the client to slow down breathing.
A client has the following laboratory values: pH of 7.55, HCO3- of 22 mm Hg, and a Pco2 of 30 mm Hg. Which action would the nurse take?
ANS: Encourage the client to slow down his breathing.
A client undergoing diagnostic testing for cancer is scheduled for magnetic resonance imaging (MRI). The nurse reinforces to the client which information about the procedure?
ANS: Expect the MRI machine to make loud noises.
A client is scheduled for an oral cholecystography. The nurse would plan to obtain what type of diet for the evening meal before the test?
ANS: Fat-free
A client is determined to be in respiratory alkalosis by blood gas analysis. The nurse would monitor this client for signs of which electrolyte disorder that could accompany the acid-base imbalance?
ANS: Hypokalemia
A client is complaining about pain when voiding. The primary health care provider prescribes a clean-catch urine specimen. The nurse would instruct the client to perform which action first when obtaining this specimen?
ANS: Instruct the client to wash her hands.
The nurse has reinforced postprocedure instructions to a client who has undergone a colonoscopy. The nurse determines that there is a need for further teaching if the client makes which statement?
ANS: It is all right to drive an hour after the test is finished.
The nurse assists the primary health care provider in performing a lumbar puncture on a 3-year-old child with leukemia suspected of central nervous system (CNS) disease. In which position would the nurse place the child during this procedure?
ANS: Lateral recumbent with the knees flexed to the abdomen and head bent with the chin resting on the chest
A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed?
ANS: Leaving the rate of the heparin infusion as is
Which action would the nurse include in the plan of care for a client following a renal scan?
ANS: No special precautions are needed except to wear gloves if coming into contact with the client's urine.
A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse would take which action after seeing the laboratory results?
ANS: Place the normal report in the client's medical record.
The nurse is reviewing the arterial blood gas results of the client. Blood gas results indicate a pH of 7.30 and a Pco2 of 50 mm Hg, and the nurse has determined that the client is experiencing respiratory acidosis. Which additional laboratory values would the nurse expect to note in this client?
ANS: Potassium 5.4 mEq/L
An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse would do which action to help the client experiencing this acid-base disorder?
ANS: Provide emotional support and reassurance.
The nurse is assisting to admit a client with a diagnosis of acute Guillain-Barré syndrome. The nurse knows that if the disease progresses to a severe level, the client will be at risk for which acid-base imbalance?
ANS: Respiratory acidosis
The nurse is caring for a client who is nervous and is hyperventilating. The nurse would monitor the client for signs of which acid-base imbalance?
ANS: Respiratory alkalosis
The client is having a lumbar puncture (LP) performed. The nurse would place the client in which position for the procedure?
ANS: Side-lying, with legs pulled up and chin to the chest
Which arterial blood gas (ABG) result would the nurse anticipate in a client who develops metabolic alkalosis after profuse vomiting for 2 days?
ANS: pH 7.49; Pco2 45; HCO3- 30
A client has just undergone a gastroscopy. Which action would be taken by the nurse as the essential postprocedure nursing intervention?
ANS: Monitoring for the gag reflex
The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 32 mm Hg (32 mm Hg). The nurse determines that these results are indicative of which acid-base disturbance?
ANS: Respiratory alkalosis
An ultrasound of the gallbladder is scheduled for the client with a suspected diagnosis of cholecystitis. Which would the nurse explain to the client about this test?
ANS: The test requires the client to lie still for short intervals.
The nurse is reviewing the serum electrolyte laboratory results of a client and finds that the client has an elevated magnesium level. Which part of the client's history is likely associated with this problem?
ANS: History of chronic laxative use
A client who has undergone a barium enema is being readied for discharge from the ambulatory care unit. Which instruction would the nurse include in instructions to the client?
ANS: The barium will cause the stools to be clay colored, but then the stool becomes normal colored.
A bone marrow aspiration is scheduled for a client suspected of having leukemia. What intervention does the nurse anticipate will be done to protect the aspiration site and client from becoming infected?
ANS: The site will be cleansed thoroughly with an antiseptic and allowed to air dry before the procedure.
A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?
ANS: Ulnar circulation
A client with ascites is scheduled for a paracentesis. The nurse is assisting the primary health care provider (PHCP) with performing the procedure. Which position would the nurse assist the client into for this procedure?
ANS: Upright
The registered nurse (RN) reviews the results of the arterial blood gas (ABG) values with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN would expect to note which on the laboratory result report?
ANS: pH 7.25, Pco2 50 mm Hg
A client with a tentative diagnosis of gastroesophageal reflux disease (GERD) is going to undergo ambulatory pH monitoring. The nurse assists in the procedure and would bring which item to the bedside?
ANS:Nasogastric (NG) tube
A client with Crohn's disease is seen by the primary health care provider, and a complete blood count (CBC) has been prescribed. The nurse reinforces instructions to the client who will be reporting to the laboratory in the morning to have the blood test drawn. The nurse gives the client which information about this test?
ANS:No special preparation is necessary.
A client with leukemia who had a bone marrow aspiration is thrombocytopenic. The nurse gives which instruction to the family as the client is discharged to home?
ANS: Watch the puncture site for bleeding for the next several days.
Which statement by the client would cause the nurse to suspect that the thyroid test results drawn on the client this morning may be inaccurate?
ANS: "I had a radionuclide test done 3 days ago."
The client has just undergone computed tomography (CT) scanning with a contrast medium. Which statement by the client demonstrates an understanding of postprocedure care?
ANS: "I should drink extra fluids for the remainder of the day."
The nurse has provided instructions to a client scheduled for a mammography regarding the procedure. Which statement by the client indicates an understanding of the procedure?
ANS: "I should not wear deodorant on the day of the test."
The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value?
ANS: 2000 mm3 (2.0 × 109/L)
The client who is scheduled for an intravenous pyelogram has been instructed to take liquid magnesium citrate on the day before the scheduled procedure. The client asks the nurse about the administration procedure for this medication. Which instruction would the nurse provide to the client?
ANS: "Take the medication on ice."
A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure?
ANS: Preventing and recognizing hyperglycemia
A client has a prescription to receive purified protein derivative (PPD) 0.1 mL intradermally (tuberculin skin test). The nurse prepares to administer the PPD and obtains a tuberculin syringe with a 26-gauge, ⅝-inch needle. Which technique would the nurse use to insert the needle?
ANS: Almost parallel to the skin with bevel side up
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription?
ANS: Holding the next dose of warfarin
A tuberculin skin test is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse checks the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which findings did the nurse identify to make this interpretation?
ANS: An area of induration at the test site measuring 7 mm
The nurse is assisting in performing an arterial blood gas (ABG) analysis on a client. The nurse initially implements which intervention after the blood gas is drawn to minimize the risk for uncontrolled bleeding?
ANS: Applying direct pressure to the site
A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, which instruction would the nurse provide the client?
ANS: Avoid eating or drinking after midnight before the test.
A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder?
ANS: Decreased respiratory depth and rate and dysrhythmias
A licensed practical nurse (LPN) is providing follow-up teaching after a client underwent an upper gastrointestinal (GI) series with diatrizoate used for contrast. The nurse instructs the client that which may occur from the diatrizoate?
ANS: Diarrhea
A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, would be reported before administering the dose of furosemide?
ANS: 3.2 mEq/L (3.2 mmol/L)
A client is to have an upper gastrointestinal (GI) series. Which nursing action would be done concerning the procedure?
ANS: Administer a laxative after the procedure because barium was administered.
The nurse is caring for a client who is going to have an arthrogram using a contrast medium. Which data collected by the nurse would be of highest priority?
ANS: Allergy to iodine or shellfish
The nurse is assisting in preparing a client for a cardiac catheterization. The nurse understands that it is important to check the client's record for which history?
ANS: Allergy to shellfish
The nurse prepares a client for the lumbar puncture procedure by which interventions? Select all that apply.
ANS: 1. Review the coagulation laboratory studies. 2.Observe the lower lumbar area for skin infections. 3.Check to see the client has a signed consent for the procedure.
The nurse is assigned to care for a client who has just returned to the nursing unit following a renal biopsy. The nurse plans to do which actions to properly care for this client for the remainder of the shift? Select all that apply.
ANS: 1. Test the urine for occult blood. 2.Observing the urine and biopsy site for bleeding.
The nurse is reinforcing instructions to a female client regarding the procedure for collecting a midstream urine sample. Which statement by the client indicates an understanding of the procedure?
ANS: "I need to collect the urine in the cup after I start to urinate."
A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value?
ANS: 15 mg/dL (5.25 mmol/L)
A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the primary health care provider for intervention?
ANS: 240 mg/dL (13.7 mmol/L)
The nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse would then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?
ANS: Hypokalemia
The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How would the nurse correctly document this observation in the medical record?
ANS: Kussmaul's respirations
The nurse is reinforcing teaching to a client about an upcoming colonoscopy procedure. The nurse would include in the instructions that the client will be placed in which position for the procedure?
ANS: Modified left lateral recumbent position
The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child. The results indicate an area of induration measuring 8 mm. Which correct interpretation would the nurse make about these results?
ANS: Negative
A primary health care provider (PHCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas, and the client is still passing brown liquid stool. Which action would the nurse take next?
ANS: Notify the primary health care provider.
A client is in respiratory alkalosis induced by gram-negative sepsis. The nurse assists in implementing which measure as the effective means to treat the problem?
ANS: Administer prescribed antibiotics.
A client who has fallen from a roof and fractured his ribs has arterial blood gas (ABG) results of: pH 7.48, Paco2 32 mm Hg, Pao2 89 mm Hg, and HCO3- 22 mEq/L. How would the nurse interpret the client's blood gas results?
ANS: Respiratory alkalosis
The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?
ANS: Metabolic acidosis
A clinic nurse has given a client the materials needed to test the stool for occult blood as part of a routine screening for colorectal cancer. When the client asks the nurse whether there are any special precautions that must be followed in doing this test, the nurse tells the client to avoid eating which food for at least a day before performing the test?
ANS: Red meat
The nurse is preparing a client for a magnetic resonance imaging (MRI) examination. Which action by the nurse is important?
ANS: Remove metallic objects from the client.
The nurse reviews the arterial blood gas results of a client and notes that the results indicate a pH of 7.30, Pco2 of 52 mm Hg, and HCO3- of 22 mEq/L. Which interpretation would the nurse correctly make about these results?
ANS: Respiratory acidosis
A client is scheduled for a digital subtraction angiography (DSA). The nurse tells the client that the test is directed toward which outcome?
ANS: Providing information about the blood vessels
Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all that apply.
ANS: 1. Client who has been vomiting for 2 days 2. Client receiving oral furosemide 40 mg daily
The nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.
ANS: 1. Client with pancreatitis 2.Malnourished client 3. Client with diabetes mellitus 4.Client with status epilepticus 5.Client with severe prolonged diarrhea
A 3-year-old child is hospitalized because of persistent vomiting. Which conditions would the nurse expect this child to be at high risk for? Select all that apply.
ANS: 1. Dehydration 2.Metabolic alkalosis
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?
ANS: Metabolic alkalosis
Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results would the nurse report? Select all that apply.
ANS: 1. Platelets 35,000 mm3 (35 × 109/L) 2. Segmented neutrophils 40% (0.40) 3. White blood cells, 3000 mm3 (3.0 × 109/L)
The nurse is providing a list of instructions to a client who is scheduled to have an electroencephalogram (EEG). Which instructions would the nurse place on the list? Select all that apply.
ANS: 1. Tea and coffee are restricted on the day of the test. 2.The test will take between 45 minutes and 2 hours. 3.The hair should be washed the evening before the test.
A gastric analysis is prescribed for a client with a suspected diagnosis of tuberculosis (TB). The nurse understands that the test is relevant in confirming this diagnosis because of which related fact?
ANS: People can frequently swallow small amounts of sputum.
The nurse is completing the laboratory requisition that will accompany an arterial blood gas (ABG) specimen sent to the laboratory for analysis. The nurse understands that which data will be needed by the laboratory for adequate evaluation of the specimen? Select all that apply.
ANS: 1.The client's temperature 2.The date the specimen was drawn 3.The time the specimen was drawn 4.Any supplemental oxygen the client is receiving
A primary health care provider prescribes a 24-hour urine collection for vanillylmandelic acid (VMA). The nurse instructs the client in the procedure for the collection of the urine. Which statement by the client would indicate a need for further teaching?
ANS: "I can take any medications if I need to before the collection."
A client is scheduled for endoscopic retrograde cholangiopancreatography (ERCP). The nurse includes which intervention in the plan of care for the client?
ANS: After the procedure, keep the client nothing by mouth (NPO) until the gag reflex returns.
The nurse is reinforcing preprocedure instructions to a client scheduled for a barium swallow at 8.00 am. Which statement by the client indicates a need for further teaching?
ANS: I will limit myself to two cigarettes only on the morning of the test.
The nurse is caring for a client with kidney failure. The nurse is told that the blood gas results indicate a pH of 7.30 and a HCO3- of 20 mm Hg, and that the client is experiencing metabolic acidosis. The nurse reviews the laboratory results and finds which value to be of concern?
ANS: Potassium level, 5.6 mEq/L
The nurse is preparing to care for a client following a lumbar puncture. The nurse plans to place the client in which position immediately after the procedure?
ANS: Prone with a pillow under the abdomen
A client has a prescription to have radial arterial blood gases (ABGs) drawn. Before drawing the sample, an Allen's test will be performed. In performing the Allen's test, which blood vessel(s) would the nurse occlude?
ANS: Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery
The nurse is caring for a client scheduled for magnetic resonance imaging (MRI). Which instruction does the nurse reinforce to the client?
ANS: Earplugs can be worn if the noise from the machine is uncomfortable.
A client with diabetes mellitus has a blood glucose level of 596 mg/dL on admission. The nurse anticipates that this client is at risk for which type of acid-base imbalance?
ANS: Metabolic acidosis
The nurse is assisting in the care of a client who had an ileostomy created a few days ago. The client has high output of drainage from the ileostomy. Based on this the nurse monitors the client for which acid-base imbalance?
ANS: Metabolic acidosis
The nurse reinforces postoperative liver biopsy instructions to a client. Which would the nurse tell the client?
ANS: Lie on the right side for 2 hours.
A pulmonary angiography is scheduled for a client suspected of having a pulmonary embolism. The nurse understands that which actions are an appropriate preprocedure care intervention? Select all that apply.
ANS: 1.Obtain a signed informed consent form. 2. Prepare the anticipated entry site for local anesthesia. 3.Inquire whether the client has any allergies to shellfish. 4.Ask whether client has ever experienced an allergy to any contrast media.
A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that a client with an ileostomy is at risk for developing?
ANS: Metabolic acidosis
A client has had a set of arterial blood gases drawn. The results are pH, 7.34; Paco2, 37 mm Hg; Pao2, 79 mm Hg; and HCO3,- 19 mEq/L. The nurse interprets that the client is experiencing which acid-base imbalance?
ANS: Metabolic acidosis
The nurse has assisted with obtaining a blood specimen for arterial blood gas (ABG) analysis. The nurse avoids doing which to properly obtain and send the specimen?
ANS: Obtain a 3-mL syringe that is used for parenteral medication.
A client who has been prescribed indomethacin for gout is asked to provide a stool sample for guaiac testing. The nurse explains that the purpose of the test is to make which determination?
ANS: Occult blood
The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse would monitor the client for which acid-base imbalance?
ANS: Respiratory acidosis
A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?
ANS: Metabolic acidosis
The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?
ANS: Metabolic alkalosis
Arterial blood gases (ABGs) are obtained on a client with pneumonia. The ABG results are pH, 7.50; Pco2, 30 mm Hg; HCO3-, 20 mEq/L; and Po2, 75 mm Hg. The nurse interprets these results and determines that which acid-base condition exists?
ANS: Respiratory alkalosis
The nurse is assisting in the care of a client for whom an arterial blood gas (ABG) must be drawn. The nurse notes that the person who draws the blood sample from the radial artery performs an Allen's test first. The nurse recognizes that this is being done to determine the adequacy of which circulations? Select all that apply.
ANS: 1. Ulnar circulation 2. Radial circulation
