Question

A person with a blood pH of 7.21 is considered to have which of the following?

Answer 1

Correct Answers:

Acidosis

Rationale :

✅ The normal blood pH range is 7.35–7.45; any value below 7.35 is considered acidotic.

✅ A pH of 7.21 indicates significant acidemia, which could result from respiratory or metabolic acidosis.

✅ Acidosis impairs enzyme function and cellular metabolism, requiring prompt assessment of underlying causes.

✅ The nurse should monitor for associated clinical signs such as confusion, hypotension, or arrhythmias.

✅ Corrective interventions depend on whether the cause is respiratory (CO2 retention) or metabolic (HCO3 loss or acid gain).

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Answer 2

Correct Answers:

Monitor the CBC, especially the neutrophil, platelet, and RBC counts.

Rationale :

🟢 Myelosuppression is a common chemotherapy complication causing bone marrow suppression and resulting in pancytopenia.

🟢 Monitoring the CBC reveals neutropenia (infection risk), thrombocytopenia (bleeding risk), and anemia (fatigue and hypoxia risk).

🟢 Early detection allows timely interventions such as neutropenic precautions, transfusions, or growth factor administration.

🟢 Myelosuppression typically occurs 7–14 days post-chemotherapy, making serial CBC monitoring essential.

🟢 Nursing care focuses on infection prevention, bleeding precautions, and energy conservation.

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Answer 3

Correct Answers:

Review the patient’s medication list to verify its accuracy and completeness. They also compare the list of current medications with new orders or prescriptions to detect any discrepancies or potential issues.

Rationale :

🔵 Medication reconciliation is a systematic process of comparing a patient’s home medications with hospital or new prescriptions to ensure accuracy.

🔵 Nurses play a critical role in identifying discrepancies, duplications, or potential drug interactions, which improves patient safety.

🔵 This process prevents adverse drug events and ensures continuity of care during transitions (admission, transfer, discharge).

🔵 It involves collaboration with the patient, caregivers, and healthcare team to clarify medication use.

🔵 Accurate reconciliation is vital in reducing medication errors and hospital readmissions.

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Answer 4

Correct Answers:

Gather subjective and objective data in order to plan and implement appropriate pain management techniques.

Rationale :

🔴 The primary goal of a nursing pain assessment is to collect comprehensive subjective and objective data to guide effective pain management.

🔴 Subjective data include the patient’s self-reported pain level, location, intensity, and quality; objective data include vital signs, facial expressions, and physical limitations.

🔴 Accurate assessment allows selection of appropriate pharmacologic and non-pharmacologic interventions tailored to the patient.

🔴 Ongoing reassessment ensures interventions are effective and promotes optimal comfort and functional recovery.

🔴 Pain assessment is a continuous, patient-centered process that informs care planning and evaluation.

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Answer 5

Correct Answers:

Saline 0.9%.

Rationale :

✅ 0.9% Normal Saline (NS) is an isotonic solution with osmolality similar to plasma, making it the fluid of choice for fluid deficit replacement.

✅ It restores intravascular volume without causing significant shifts between intracellular and extracellular compartments.

✅ Isotonic fluids are indicated in conditions like hypovolemia, dehydration, and shock to maintain adequate perfusion.

✅ Hypertonic (3% saline) and hypotonic (0.45% saline) solutions are inappropriate for initial fluid deficit management.

✅ NS is safe for rapid volume expansion in most patients unless contraindicated (e.g., heart failure).

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Answer 6

Correct Answers:

Decrease pain by increasing circulation to a painful area and relaxing tense muscles.

Rationale :

🟢 Heat therapy promotes vasodilation, which increases blood flow to the injured area, reducing muscle spasms and pain.

🟢 Enhanced circulation delivers oxygen and nutrients that support tissue healing and waste product removal.

🟢 Relaxation of tense muscles reduces nerve compression, improving mobility and comfort.

🟢 Heat is particularly effective for muscle sprains, strains, and chronic pain, not acute inflammation.

🟢 It should be applied intermittently to prevent burns or tissue damage.

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Answer 7

Correct Answers:

Check the oxygen (O2) saturation.

Rationale :

🔵 Agitation and confusion in a post-op patient can indicate hypoxia, making oxygen assessment the highest priority.

🔵 Post-anesthesia respiratory depression or hypoventilation can cause decreased oxygenation, requiring immediate correction.

🔵 Checking O2 saturation follows the ABCs (Airway, Breathing, Circulation), prioritizing oxygenation before other interventions.

🔵 Addressing hypoxia early prevents respiratory failure or cardiac complications.

🔵 Restraints and medications should not be used until oxygenation status is confirmed and corrected.

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Answer 8

Correct Answers:

Gloving before wiping pink sputum off the bedrail.

Rationale :

🔴 Standard precautions require gloves whenever there is potential contact with blood, body fluids, or contaminated surfaces.

🔴 Wiping pink sputum poses a risk of pathogen transmission, making gloves essential for infection prevention.

🔴 Other PPE (gown, mask, goggles) is used only if there is a risk of splashing or aerosolization.

🔴 Following standard precautions protects both patient and healthcare workers from cross-infection.

🔴 Hand hygiene should be performed immediately after glove removal.

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Answer 9

Correct Answers:

Hypomagnesemia - Chronic alcoholism.
Hyperkalemia - Kidney failure.

Rationale :

Hypomagnesemia – Chronic alcoholism

🟡 Chronic alcohol use leads to poor dietary intake and renal magnesium loss, causing hypomagnesemia.

🟡 Symptoms include neuromuscular irritability, arrhythmias, and seizures, requiring magnesium replacement.

🟡 Monitoring Mg levels is crucial in alcoholic patients to prevent cardiac complications.

Hyperkalemia – Kidney failure

🟡 Renal failure impairs potassium excretion, leading to hyperkalemia.

🟡 High potassium levels cause muscle weakness, ECG changes (peaked T waves), and life-threatening arrhythmias.

🟡 Treatment may include calcium gluconate, insulin with glucose, or dialysis.

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Answer 10

Correct Answers:

Give the patient a pamphlet that reinforces teaching done by the nurse.

Rationale :

🔷 Assistive personnel (AP) can reinforce but not perform initial patient teaching or evaluation, which is the nurse’s responsibility.

🔷 Providing pre-approved educational materials is within AP scope because it does not require clinical judgment.

🔷 Nurses remain responsible for assessing understanding and patient learning outcomes.

🔷 Delegation ensures time efficiency while maintaining patient education quality.

🔷 The AP’s role is supportive, not instructional.

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Managing Adult Care 1-Samuel merit University

No.

1 :
A person with a blood pH of 7.21 is considered to have which of the following?

2 :
Myelosuppression is one of the most common effects of chemotherapy. How would the nurse assess for this condition?

3 :
Which statement best describes the nurse’s role in medication reconciliation?

4 :
A priority goal of the nursing pain assessment is to:

5 :
Which IV solution would the nurse anticipate administering to a patient with fluid deficit who requires isotonic fluid replacement?

6 :
A heating pad is ordered for a patient with a lumbar sprain. The nurse knows that the purpose of the heating pad is to:

7 :
A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

8 :
Which infection control actions would the nurse include in the use of standard precautions?

9 :
A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance?

10 :
Which actions included in the discharge teaching plan can the nurse delegate to assistive personnel (AP)?

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Managing Adult Care 1-Samuel merit University

No.

1 : A person with a blood pH of 7.21 is considered to have which of the following?

2 : Myelosuppression is one of the most common effects of chemotherapy. How would the nurse assess for this condition?

3 : Which statement best describes the nurse’s role in medication reconciliation?

4 : A priority goal of the nursing pain assessment is to:

5 : Which IV solution would the nurse anticipate administering to a patient with fluid deficit who requires isotonic fluid replacement?

6 : A heating pad is ordered for a patient with a lumbar sprain. The nurse knows that the purpose of the heating pad is to:

7 : A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

8 : Which infection control actions would the nurse include in the use of standard precautions?

9 : A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance?

10 : Which actions included in the discharge teaching plan can the nurse delegate to assistive personnel (AP)?

1 :
A person with a blood pH of 7.21 is considered to have which of the following?

2 :
Myelosuppression is one of the most common effects of chemotherapy. How would the nurse assess for this condition?

3 :
Which statement best describes the nurse’s role in medication reconciliation?

4 :
A priority goal of the nursing pain assessment is to:

5 :
Which IV solution would the nurse anticipate administering to a patient with fluid deficit who requires isotonic fluid replacement?

6 :
A heating pad is ordered for a patient with a lumbar sprain. The nurse knows that the purpose of the heating pad is to:

7 :
A patient who is just waking up after having hip replacement surgery is agitated and confused. Which action should the nurse take first?

8 :
Which infection control actions would the nurse include in the use of standard precautions?

9 :
A nurse is caring for patients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance?

10 :
Which actions included in the discharge teaching plan can the nurse delegate to assistive personnel (AP)?