Question

A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Have the client breath into a paper bag.

Rationale :

💎 Respiratory alkalosis occurs due to hyperventilation, which causes excessive CO₂ loss and increased blood pH.

💎 Breathing into a paper bag allows the client to rebreathe exhaled CO₂, restoring acid-base balance.

💎 The goal is to increase PaCO₂ and correct alkalosis symptoms (e.g., dizziness, lightheadedness).

💎 Sodium bicarbonate is contraindicated—it would worsen alkalosis.

💎 Insulin or head-lowering positions are unrelated to correcting hyperventilation-induced alkalosis.

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Answer 2

Correct Answers:

Monitor dally weight
Encourage low-sodium diet
Administer prescribed diuretics

Rationale :

🔷Monitor daily weight Daily weights are the most accurate indicator of fluid balance in clients with heart failure.

🔷A gain of more than 2 lb in 24 hours suggests fluid retention and worsening heart failure.

🔷Encourage low-sodium diet Sodium promotes water retention, increasing preload and worsening edema and pulmonary congestion.

🔷 Low-sodium diets reduce fluid overload and cardiac workload.

🔷Administer prescribed diuretics Diuretics (e.g., furosemide) promote fluid excretion, reducing edema and improving breathing.

🔷 Monitoring urine output and electrolyte balance is critical.

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Answer 3

Correct Answers:

Increased reabsorption of water in the nephrons of the kidneys

Rationale :

🔶 Dehydration triggers increased secretion of ADH (antidiuretic hormone) from the posterior pituitary gland.

🔶 ADH acts on the renal collecting ducts, increasing water reabsorption and decreasing urine output.

🔶 This mechanism conserves body water and helps restore plasma volume and blood pressure.

🔶 The kidneys respond by concentrating urine, making it darker and smaller in volume.

🔶 This is a normal homeostatic response to fluid deficit.

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Answer 4

Correct Answers:

Type O negative

Rationale :

💎 Type O negative blood is the universal donor, containing no A, B, or Rh antigens, preventing immune reactions.

💎 Clients with O negative blood can only safely receive O negative transfusions due to the presence of both anti-A and anti-B antibodies.

💎 Transfusing incompatible blood can cause hemolytic transfusion reactions, leading to renal failure or death.

💎 Always verify blood type, crossmatch results, and two-nurse confirmation before transfusion.

💎 Compatibility ensures safe and effective oxygen-carrying replacement.

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Answer 5

Correct Answers:

Request assistance from another nurse or healthcare professional.

Rationale :

🔷 After two unsuccessful venipuncture attempts, the nurse should stop and seek assistance to prevent tissue trauma and client discomfort.

🔷 Most institutional policies limit attempts to two per clinician to maintain vein integrity.

🔷 Additional attempts can lead to hematoma formation, phlebitis, or nerve injury.

🔷 The assisting nurse may select a different site or use advanced techniques (e.g., ultrasound-guided).

🔷 This action prioritizes client safety and professional collaboration.

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Answer 6

Correct Answers:

Request assistance from another nurse or healthcare professional.

Rationale :

🔷 After two unsuccessful venipuncture attempts, the nurse should stop and seek assistance to prevent tissue trauma and client discomfort.

🔷 Most institutional policies limit attempts to two per clinician to maintain vein integrity.

🔷 Additional attempts can lead to hematoma formation, phlebitis, or nerve injury.

🔷 The assisting nurse may select a different site or use advanced techniques (e.g., ultrasound-guided).

🔷 This action prioritizes client safety and professional collaboration.

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Answer 7

Correct Answers:

0.9% Sodium Chloride (Normal Saline)

Rationale :

🔹 Maintains osmotic balance — Normal saline is isotonic, meaning it has the same concentration as body fluids, preventing fluid shifts between compartments.

🔹 Restores intravascular volume — It expands the extracellular fluid (ECF), correcting hypovolemia caused by dehydration.

🔹 Prevents electrolyte disturbance — It does not alter sodium or water distribution excessively.

🔹 Used in resuscitation — Safe for bolus administration in shock, trauma, and dehydration.

🔹 Compatible with blood products — It’s the only IV fluid used safely with transfusions.

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Answer 8

Correct Answers:

To assess the patency of the radial and ulnar arteries

Rationale :

♦ Evaluates blood flow — Ensures both arteries (radial and ulnar) can adequately perfuse the hand.

♦ Prevents ischemia — Confirms collateral circulation before arterial puncture.

♦ Safety check — Protects hand tissues in case of arterial occlusion post-procedure.

♦ Quick bedside procedure — Takes 5–15 seconds; pink return confirms adequate flow.

♦ Prevents complications — Avoids tissue necrosis from impaired circulation

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Answer 9

Correct Answers:

Blood cultures (sterile), PTT (light blue citrate), CMP (light green heparin), CBC (lavender EDTA)

Rationale :

✔ Prevents cross-contamination — Correct sequence ensures additives don’t alter results.

✔ Sterility maintained — Blood cultures drawn first to avoid bacterial contamination.

✔ Accurate coagulation testing — Citrate tube (light blue) drawn before heparin or EDTA tubes.

✔ Protects chemistry integrity — Heparin tubes follow coagulation studies.

✔ Final draw — EDTA last for hematology, preventing carryover of anticoagulants.

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Answer 10

Correct Answers:

Place the patient's bed in the lowest position and ensure the call bell is within reach.

Rationale :

🔸 Promotes safety — Reduces injury risk from unexpected weakness or confusion.

🔸 Addresses muscle weakness — Low bed prevents injury from slips or sudden collapse.

🔸 Enhances supervision — Ensures the patient can request help when needed.

🔸 Implements fall precautions — Essential in all hypercalcemia cases due to lethargy.

🔸 Supports nursing priority — Safety and fall prevention are top priorities for high-risk clients.

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QLexNursing

1 :
A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?

2 :
A patient with a history of heart failure presents with edema, shortness of breath, and elevated blood pressure. Which nursing interventions should be prioritized to address this fluid imbalance? (Select all that apply)

3 :
A patient is experiencing dehydration. Which physiological response involving antidiuretic hormone (ADH) would you expect to occur in the kidneys?

4 :
A patient with type O negative blood requires a transfusion. Which blood type should the nurse choose to ensure compatibility?

5 :
During a venipuncture procedure, a nurse is unable to obtain blood from a patient's antecubital vein after two attempts. What should be the nurses next course of action.

6 :
During a venipuncture procedure, a nurse is unable to obtain blood from a patient's antecubital vein after two attempts. What should be the nurses next course of action?

7 :
A patient is admitted with dehydration and requires fluid replacement. Which of the following isotonic IV solutions would be most appropriate to administer to restore fluid volume without altering electrolyte balance?

8 :
A nurse is preparing to perform the Allen test on a patient prior to obtaining an arterial blood gas sample. What is the purpose of performing the Allen test?

9 :
Your client has a blood specimen ordered. The specimens ordered are blood cultures (sterile), CBC (Lavender EDTA), CMP (light green heparin tube Seda PTT (light blue citrate tube). What order is the correct steps to draw the specimen?

10 :
A patient with hypercalcemia is at risk for falls due to muscle weakness and altered mental status. Which nursing intervention is most appropriate to prevent falls in this patient?

QLexNursing

1 : A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?

2 : A patient with a history of heart failure presents with edema, shortness of breath, and elevated blood pressure. Which nursing interventions should be prioritized to address this fluid imbalance? (Select all that apply)

3 : A patient is experiencing dehydration. Which physiological response involving antidiuretic hormone (ADH) would you expect to occur in the kidneys?

4 : A patient with type O negative blood requires a transfusion. Which blood type should the nurse choose to ensure compatibility?

5 : During a venipuncture procedure, a nurse is unable to obtain blood from a patient's antecubital vein after two attempts. What should be the nurses next course of action.

6 : During a venipuncture procedure, a nurse is unable to obtain blood from a patient's antecubital vein after two attempts. What should be the nurses next course of action?

7 : A patient is admitted with dehydration and requires fluid replacement. Which of the following isotonic IV solutions would be most appropriate to administer to restore fluid volume without altering electrolyte balance?

8 : A nurse is preparing to perform the Allen test on a patient prior to obtaining an arterial blood gas sample. What is the purpose of performing the Allen test?

9 : Your client has a blood specimen ordered. The specimens ordered are blood cultures (sterile), CBC (Lavender EDTA), CMP (light green heparin tube Seda PTT (light blue citrate tube). What order is the correct steps to draw the specimen?

10 : A patient with hypercalcemia is at risk for falls due to muscle weakness and altered mental status. Which nursing intervention is most appropriate to prevent falls in this patient?

1 :
A nurse is assisting with the care of a client who has respiratory alkalosis and is hyperventilating. Which of the following actions should the nurse take?

2 :
A patient with a history of heart failure presents with edema, shortness of breath, and elevated blood pressure. Which nursing interventions should be prioritized to address this fluid imbalance? (Select all that apply)

3 :
A patient is experiencing dehydration. Which physiological response involving antidiuretic hormone (ADH) would you expect to occur in the kidneys?

4 :
A patient with type O negative blood requires a transfusion. Which blood type should the nurse choose to ensure compatibility?

5 :
During a venipuncture procedure, a nurse is unable to obtain blood from a patient's antecubital vein after two attempts. What should be the nurses next course of action.

6 :
During a venipuncture procedure, a nurse is unable to obtain blood from a patient's antecubital vein after two attempts. What should be the nurses next course of action?

7 :
A patient is admitted with dehydration and requires fluid replacement. Which of the following isotonic IV solutions would be most appropriate to administer to restore fluid volume without altering electrolyte balance?

8 :
A nurse is preparing to perform the Allen test on a patient prior to obtaining an arterial blood gas sample. What is the purpose of performing the Allen test?

9 :
Your client has a blood specimen ordered. The specimens ordered are blood cultures (sterile), CBC (Lavender EDTA), CMP (light green heparin tube Seda PTT (light blue citrate tube). What order is the correct steps to draw the specimen?

10 :
A patient with hypercalcemia is at risk for falls due to muscle weakness and altered mental status. Which nursing intervention is most appropriate to prevent falls in this patient?