Question

A telemetry nurse has received bedside report on several clients. Which client is at the greatest risk for hypernatremia?

Answer 1

Correct Answers:

A client with diabetes insipidus who is unresponsive

Rationale :

💧 Diabetes insipidus causes extreme free-water loss because the kidneys cannot retain water without ADH.

💧 This leads to severe dehydration and rapid hypernatremia, often >160 mEq/L.

💧 An unresponsive DI client suggests critical sodium elevation causing neurologic compromise (confusion → seizures → coma).

💧 This makes Client C the highest-risk and most unstable.

❌ Why Others Are Not Highest Risk

Adrenal insufficiency → risk is hyponatremia, not hypernatremia.

CHF + fluid restriction → mild sodium rise possible, but not critical.

Heat stroke + 0.45% NaCl → hypotonic fluid → lowers sodium, not raises it.

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Answer 2

Correct Answers:

Stridor

Rationale :

🫁 Stridor indicates upper airway obstruction, usually from swelling of the larynx during anaphylaxis.

🫁 This is an airway emergency — the client's airway may close within minutes.

🫁 When stridor occurs after an IV antibiotic initiation, it strongly suggests a severe Type I hypersensitivity reaction involving:

airway swelling

bronchospasm

impending respiratory arrest

🫁 Immediate actions include stopping the infusion, administering IM epinephrine, providing high-flow oxygen, preparing for intubation, and notifying the provider.

🫁 NO other symptom listed is as immediately life-threatening.

❌ Others (Broad)

Hives on torso → Allergic reaction but NOT airway-threatening.

Abdominal pain → Common side effect or mild reaction.

Nausea → Mild reaction; not life-threatening.

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Answer 3

Correct Answers:

carbonic acid-bicarbonate system

Rationale :

🧪 The carbonic acid–bicarbonate buffering system is the major extracellular buffering system responsible for maintaining normal blood pH.

🧪 It works by the chemical reaction:

CO₂ + H₂O ⇌ H₂CO₃ ⇌ H⁺ + HCO₃⁻

🧪 The lungs regulate CO₂ (acid), and the kidneys regulate HCO₃⁻ (base).

🧪 Because both organs can quickly modify the components of this system, it provides rapid and powerful pH stabilization.

🧪 Protein and phosphate buffers work intracellularly but are not strong enough alone to maintain pH during major shifts.

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Answer 4

Correct Answers:

Partially compensated metabolic acidosis

Rationale :

📈 First, identify what’s abnormal:

HCO₃ is low (18) → metabolic acidosis

PaCO₂ is low (32) → indicates lungs are compensating by blowing off CO₂

📈 The pH is in the normal range (7.35–7.45) but leaning toward acidic → showing full compensation, not partial.

📈 FULL compensation means the body corrected the pH, even though CO₂ and HCO₃ remain abnormal.

📈 This pattern typically appears in:

chronic diarrhea

renal failure

ketoacidosis (late stage with compensation)

❌ Why Others Are Wrong

A & B (partial compensation) → pH must still be abnormal.

respiratory acidosis → would show HIGH PaCO₂ and HIGH HCO₃.

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Answer 5

Correct Answers:

Blood pressure of 88/52 mmHg

Rationale :

🫀 Fluid volume deficit decreases circulating blood volume, which lowers stroke volume and cardiac output.

🫀 A BP of 88/52 indicates hemodynamic instability and possible hypovolemic shock.

🫀 This threatens perfusion to vital organs such as the kidneys, brain, and heart.

🫀 Immediate intervention is required:

IV isotonic fluids (NS or LR)

frequent monitoring

strict I&O

🫀 Hypotension is always the MOST life-threatening complication of FVD.

❌ Other findings (Broad)

HR 116 → expected compensation, not the priority.

Na 147 → mild hypernatremia, common with dehydration.

SpO₂ 95% → normal.

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Answer 6

Correct Answers:

Blood pressure of 88/52 mmHg

Rationale :

🚨 A BP of 88/52 mmHg indicates hemodynamic instability caused by low circulating volume.

🚨 This means the heart cannot maintain adequate perfusion to vital organs such as the kidneys, brain, and heart.

🚨 Severe hypotension in fluid deficit suggests impending hypovolemic shock, which can quickly progress to organ failure.

🚨 The nurse must initiate actions like rapid isotonic IV fluids, positioning, frequent vitals, and notifying the provider immediately.

🚨 This finding is more life-threatening than tachycardia, mild hypernatremia, or normal oxygen saturation.

❌ Why Other Options Are Not Priority

— Na 147 (⚪ Mild hypernatremia) → common in dehydration; not emergent.

— SpO₂ 95% (🫁 Normal oxygenation) → no respiratory compromise.

— HR 116 (❤️ Expected compensation) → tachycardia is normal in volume deficit and not the most dangerous.

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Answer 7

Correct Answers:

83

Rationale :

🔢 Total volume: 250 mL

🔢 Drop factor: 20 gtt/mL

🔢 Time: 1 hour = 60 minutes

🔢 250 mL ÷ 60 min = 4.17 mL/min

🔢 4.17 mL × 20 gtt/mL = 83.4 gtt/min

🔢 Rounded: 83 gtt/min

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Answer 8

Correct Answers:

Decreased respiratory rate

Rationale :

🫁 Respiratory acidosis happens when the client retains CO₂ due to inadequate ventilation.

🫁 If the respiratory rate decreases, the client ventilates even less → CO₂ rises → acidosis worsens.

🫁 This leads to declining LOC, respiratory arrest, and organ dysfunction.

🫁 A falling respiratory rate indicates fatigue, CO₂ narcosis, or loss of airway drive, all emergency concerns.

🫁 Increasing LOC or pulse strength does NOT align with worsening acidosis.

❌ Other Options

Increased pulse strength → nonspecific, not linked to worsening acidosis.

Decreased lethargy → indicates improvement, not worsening.

Increased LOC → also improvement.

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Answer 9

Correct Answers:

Absent breath sounds on the left side

Rationale :

⚠️ Thoracentesis puts the client at risk for pneumothorax due to lung puncture.

⚠️ Absent breath sounds on the affected side is the most classic sign of pneumothorax and indicates lung collapse.

⚠️ This can rapidly progress to respiratory distress and tension pneumothorax, requiring immediate intervention (e.g., chest tube).

⚠️ Serous drainage and mild tachycardia are expected and not emergencies.

⚠️ Pain at insertion site is common and manageable but not dangerous.

❌ Why Others Aren’t Priority

Serous drainage → normal finding.

Pain 5/10 → expected; not emergent.

HR 106 → mild tachycardia; expected after fluid removal.

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Answer 10

Correct Answers:

Active artificial immunity

Rationale :

💉 Vaccines work by giving the immune system a controlled exposure to antigens.

💉 The body responds by producing its own antibodies and memory cells, providing long-lasting protection.

💉 Because the immunity comes from an injection, it is artificial, not natural.

💉 Active immunity requires the immune system to actively create antibodies, unlike passive immunity which provides ready-made antibodies.

❌ Why Others Are Incorrect

Active natural immunity → comes from surviving an actual infection.

Passive artificial immunity → from receiving injected antibodies (e.g., immunoglobulin).

Passive natural immunity → maternal antibodies passed via placenta or breastfeeding.

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QLexNursing

1 :
A telemetry nurse has received bedside report on several clients. Which client is at the greatest risk for hypernatremia?

2 :
The nurse starts an intravenous infusion of antibiotics for a client with an infection. What finding requires immediate follow-up by the nurse?

3 :
Complete the following sentence by choosing from the list of options. To maintain acid-base balance in the body, the primary buffer system is the which causes ?

4 :
Interpret the following
ABG: pH 7.36,
PaCO2 32 mmHg
HCO3 18 mEq/L.
Based on these ABG values, the client is experiencing:

5 :
The nurse is assessing a client with fluid volume deficit. Which finding requires immediate follow-up by the nurse?

6 :
The nurse is assessing a client with fluid volume deficit. Which finding requires immediate follow-up by the nurse? Answers: A-D

7 :
A nurse prepares to administer gentamicin 800 mg in 250 mL of 5% dextrose in water (D5W) to be infused over 1 hour. The drop factor of the tubing is 20 gtt/mL. At what rate will the nurse set the infusion?

8 :
The nurse provides prescribed treatments to a client with respiratory acidosis. What finding indicates to the nurse that the client's condition is worsening?

9 :
The nurse assesses a client following a thoracentesis procedure to drain fluid from the left pleural space. What finding should the nurse identify as the priority?

10 :
What type of immunity does a person gain when they receive the pertussis vaccine?

QLexNursing

1 : A telemetry nurse has received bedside report on several clients. Which client is at the greatest risk for hypernatremia?

2 : The nurse starts an intravenous infusion of antibiotics for a client with an infection. What finding requires immediate follow-up by the nurse?

3 : Complete the following sentence by choosing from the list of options. To maintain acid-base balance in the body, the primary buffer system is the which causes ?

4 : Interpret the followingABG: pH 7.36,PaCO2 32 mmHgHCO3 18 mEq/L.Based on these ABG values, the client is experiencing:

5 : The nurse is assessing a client with fluid volume deficit. Which finding requires immediate follow-up by the nurse?

6 : The nurse is assessing a client with fluid volume deficit. Which finding requires immediate follow-up by the nurse? Answers: A-D

7 : A nurse prepares to administer gentamicin 800 mg in 250 mL of 5% dextrose in water (D5W) to be infused over 1 hour. The drop factor of the tubing is 20 gtt/mL. At what rate will the nurse set the infusion?

8 : The nurse provides prescribed treatments to a client with respiratory acidosis. What finding indicates to the nurse that the client's condition is worsening?

9 : The nurse assesses a client following a thoracentesis procedure to drain fluid from the left pleural space. What finding should the nurse identify as the priority?

10 : What type of immunity does a person gain when they receive the pertussis vaccine?

1 :
A telemetry nurse has received bedside report on several clients. Which client is at the greatest risk for hypernatremia?

2 :
The nurse starts an intravenous infusion of antibiotics for a client with an infection. What finding requires immediate follow-up by the nurse?

3 :
Complete the following sentence by choosing from the list of options. To maintain acid-base balance in the body, the primary buffer system is the which causes ?

4 :
Interpret the following
ABG: pH 7.36,
PaCO2 32 mmHg
HCO3 18 mEq/L.
Based on these ABG values, the client is experiencing:

5 :
The nurse is assessing a client with fluid volume deficit. Which finding requires immediate follow-up by the nurse?

6 :
The nurse is assessing a client with fluid volume deficit. Which finding requires immediate follow-up by the nurse? Answers: A-D

7 :
A nurse prepares to administer gentamicin 800 mg in 250 mL of 5% dextrose in water (D5W) to be infused over 1 hour. The drop factor of the tubing is 20 gtt/mL. At what rate will the nurse set the infusion?

8 :
The nurse provides prescribed treatments to a client with respiratory acidosis. What finding indicates to the nurse that the client's condition is worsening?

9 :
The nurse assesses a client following a thoracentesis procedure to drain fluid from the left pleural space. What finding should the nurse identify as the priority?

10 :
What type of immunity does a person gain when they receive the pertussis vaccine?