Question

A nurse is collecting data on a client who has respiratory acidosis. Which of the following findings should the nurse expect?

Answer 1

Correct Answers:

Lethargy

Rationale :

🟢 Respiratory acidosis results from CO₂ retention, which causes the blood to become more acidic and affects the central nervous system.

🟢 Elevated CO₂ levels (hypercapnia) can lead to symptoms such as lethargy, confusion, and even stupor.

🟢 The brain is particularly sensitive to pH changes, and the decreased excitability can impair mental alertness.

🟢 This contrasts with respiratory alkalosis, where symptoms like tingling and numbness are more typical.

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Answer 2

Correct Answers:

Spirituality can increase the quality of life.

Rationale :

🟣 For clients who are nearing the end of life, spirituality often provides comfort, purpose, and a sense of peace.

🟣 It has been linked to enhanced emotional well-being, increased resilience, and better coping with terminal illness.

🟣 Many clients find that spiritual support helps reduce anxiety, fear of death, and isolation, improving their overall quality of life.

🟣 Integrating spiritual care into palliative care can have a significant positive impact on patient satisfaction and comfort.

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Answer 3

Correct Answers:

Monitor the client's BP every 5 minutes.

Rationale :

🔴 A blood pressure of 185/130 mm Hg indicates a hypertensive crisis, which requires rapid BP monitoring to guide treatment.

🔴 Administering IV antihypertensives can cause sudden BP drops, so close monitoring is essential to prevent organ hypoperfusion.

🔴 The first priority in hypertensive emergencies is stabilizing BP safely and effectively, which requires frequent reassessment.

🔴 Lifestyle changes and dietary advice are important but are not the immediate concern in acute management.

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Answer 4

Correct Answers:

Irregular respirations

Rationale :

🟡 As clients approach death, they often develop Cheyne-Stokes or irregular breathing patterns, reflecting changes in brainstem function.

🟡 Respiratory effort becomes variable, and periods of apnea may alternate with rapid breaths.

🟡 These changes are a normal part of the dying process and often indicate that death is near.

🟡 Recognizing this sign can help nurses prepare families and adjust the plan of care to focus on comfort measures.

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Answer 5

Correct Answers:

Cardiac dysrhythmias

Rationale :

🔵 A potassium level of 3.0 mEq/L indicates hypokalemia, which significantly affects cardiac muscle repolarization.

🔵 Low potassium levels can lead to ventricular arrhythmias, flattened T waves, and U waves on ECG.

🔵 Furosemide is a loop diuretic that increases urinary potassium loss, making dysrhythmia a serious potential outcome.

🔵 The nurse should monitor ECG and consider potassium replacement to prevent life-threatening complications.

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Answer 6

Correct Answers:

Level I evidence is considered to be the best evidence to support EBP

Rationale :

📘 Level I evidence represents the highest quality in the hierarchy of evidence and includes systematic reviews and meta-analyses of randomized controlled trials (RCTs).

📘 This level is considered the gold standard because it synthesizes multiple well-designed studies to provide reliable and generalizable conclusions.

📘 It serves as the strongest foundation for making clinical decisions and developing evidence-based guidelines.

📘 Lower levels (e.g., expert opinion or qualitative studies) are valuable but less rigorous than Level I.

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Answer 7

Correct Answers:

A patient with coronary artery disease (CAD) who reports chest pain radiating to the jaw.

Rationale :

🟥 Chest pain radiating to the jaw is a classic warning sign of myocardial infarction, especially in patients with known CAD.

🟥 This symptom suggests potential cardiac ischemia, which requires immediate evaluation and intervention to prevent cardiac arrest.

🟥 The other clients are stable or chronic in nature, but active chest pain with radiation is an emergency.

🟥 Early assessment and management can prevent myocardial damage and improve outcomes.

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Answer 8

Correct Answers:

They'll improve your circulation to keep blood from pooling in your legs."

Rationale :

🟢 Antiembolism stockings are designed to promote venous return from the lower extremities to reduce the risk of deep vein thrombosis (DVT).

🟢 They apply graduated compression, which helps prevent blood pooling and clot formation after surgery.

🟢 These stockings are especially useful during the postoperative period when clients may be immobile or less active.

🟢 They are part of standard DVT prophylaxis in surgical clients.

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Answer 9

Correct Answers:

Witness the client's signature.

Rationale :

🔵 The nurse’s role in the informed consent process is to witness the client’s signature and ensure that the client is signing voluntarily.

🔵 It is the provider's responsibility to explain the procedure, risks, benefits, and alternatives.

🔵 The nurse should verify that the client is competent, understands the information, and has not been coerced.

🔵 If the client appears confused or unsure, the nurse should notify the provider for clarification before witnessing the signature.

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Answer 10

Correct Answers:

The ST segment is elevated above the isoelectric line.

Rationale :

❤️ ST elevation on an ECG is a hallmark of acute myocardial infarction (STEMI) and indicates active myocardial injury.

❤️ This finding requires immediate action, often including activation of the cardiac catheterization team for reperfusion therapy.

❤️ Other intervals like PR, QT, or QRS may vary with different conditions but do not specifically signal infarction.

❤️ Recognizing ST elevation early is critical to reduce cardiac muscle damage and mortality.

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QLexNursing

1 :
A nurse is collecting data on a client who has respiratory acidosis. Which of the following findings should the nurse expect?

2 :
A nurse is assisting with teaching a class about the effects of spirituality for clients who are near the end of life. Which of the following information should the nurse include?

3 :
A nurse is administering an IV antihypertensive to a client who has a BP of 185/130 mm Hg. Which of the following actions should the nurse take first?

4 :
A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect?

5 :
A nurse is reviewing the laboratory results of a client who is taking furosemide and notes the client's potassium level is 3.0 mEq/L. Which of the following physiological responses should the nurse expect related to the client's hypokalemia?

6 :
A charge nurse is discussing evidence-based practice (EBP) with a newly licensed nurse. Which of the following information should the nurse include when discussing the hierarchy of evidence?

7 :
The nurse is caring for a group of patients. Which of the the following patients should the nurse evaluate first?

8 :
A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

9 :
A client is about to undergo an elective surgical procedure. Which of the following is the role of the nurse providing preoperative care regarding informed consent?

10 :
A nurse is assisting with the care of a client who was admitted to the cardiac telemetry unit after he experienced chest pain, dyspnea and diaphoresis. Which of the following electrocardiogram (ECG) findings is a manifestation of acute myocardial infarction?

QLexNursing

1 : A nurse is collecting data on a client who has respiratory acidosis. Which of the following findings should the nurse expect?

2 : A nurse is assisting with teaching a class about the effects of spirituality for clients who are near the end of life. Which of the following information should the nurse include?

3 : A nurse is administering an IV antihypertensive to a client who has a BP of 185/130 mm Hg. Which of the following actions should the nurse take first?

4 : A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect?

5 : A nurse is reviewing the laboratory results of a client who is taking furosemide and notes the client's potassium level is 3.0 mEq/L. Which of the following physiological responses should the nurse expect related to the client's hypokalemia?

6 : A charge nurse is discussing evidence-based practice (EBP) with a newly licensed nurse. Which of the following information should the nurse include when discussing the hierarchy of evidence?

7 : The nurse is caring for a group of patients. Which of the the following patients should the nurse evaluate first?

8 : A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

9 : A client is about to undergo an elective surgical procedure. Which of the following is the role of the nurse providing preoperative care regarding informed consent?

10 : A nurse is assisting with the care of a client who was admitted to the cardiac telemetry unit after he experienced chest pain, dyspnea and diaphoresis. Which of the following electrocardiogram (ECG) findings is a manifestation of acute myocardial infarction?

1 :
A nurse is collecting data on a client who has respiratory acidosis. Which of the following findings should the nurse expect?

2 :
A nurse is assisting with teaching a class about the effects of spirituality for clients who are near the end of life. Which of the following information should the nurse include?

3 :
A nurse is administering an IV antihypertensive to a client who has a BP of 185/130 mm Hg. Which of the following actions should the nurse take first?

4 :
A nurse is collecting data from a client who is at the end of life. Which of the following findings should the nurse expect?

5 :
A nurse is reviewing the laboratory results of a client who is taking furosemide and notes the client's potassium level is 3.0 mEq/L. Which of the following physiological responses should the nurse expect related to the client's hypokalemia?

6 :
A charge nurse is discussing evidence-based practice (EBP) with a newly licensed nurse. Which of the following information should the nurse include when discussing the hierarchy of evidence?

7 :
The nurse is caring for a group of patients. Which of the the following patients should the nurse evaluate first?

8 :
A nurse is reinforcing preoperative teaching with a client who will undergo abdominal surgery. The nurse explains that the client will wear antiembolism stockings after the procedure. When the client asks what the stockings do, which of the following responses should the nurse make?

9 :
A client is about to undergo an elective surgical procedure. Which of the following is the role of the nurse providing preoperative care regarding informed consent?

10 :
A nurse is assisting with the care of a client who was admitted to the cardiac telemetry unit after he experienced chest pain, dyspnea and diaphoresis. Which of the following electrocardiogram (ECG) findings is a manifestation of acute myocardial infarction?