The loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid; this results in an alkalotic condition. Options 3 and 4 deal with respiratory problems. Option 1 relates to acidosis.
Kussmaul's respirations are abnormally deep, regular, and increased in rate. In apnea, respirations cease for several seconds. In bradypnea, respirations are regular but abnormally slow. In hyperpnea, respirations are labored and increased in depth and rate
Please select 4 correct answers
An eye patch or shield is applied to protect the eye and prevent any further detachment. Educating the client regarding symptoms is necessary because the client is at risk for subsequent retinal detachment. Positioning, activity restrictions, and eye patches hinder the client in the performance of activities of daily living, and the client needs the nurse's assistance with these activities. Eye medications are prescribed postoperatively, and hemorrhage is also a risk post surgery. Coughing is not encouraged because this can increase intraocular pressure and harm the client.
Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted.
Children should not be given herbal therapies, especially in the home and without professional supervision. There are no general contraindications for the clients described in options 1, 2, and 4.
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The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.
Please select 3 correct answers
Severe preeclampsia is characterized by blood pressure higher than 160/110 mmHg, proteinuria 3+ or higher, and oliguria. Seizures (convulsions) are present in eclampsia and are not a characteristic of severe preeclampsia. Muscle cramps and contractions are not findings noted in severe preeclampsia, although the client is monitored for these occurrences.
Please select 3 correct answers
Thyrotoxic crisis (thyroid storm) is an acute, potentially life-threatening state of extreme thyroid activity that represents a breakdown in the body's tolerance to a chronic excess of thyroid hormones. The clinical manifestations include fever greater than 100° F, severe tachycardia, flushing and sweating, and marked agitation and restlessness. Delirium and coma can occur.
Please select 3 correct answers
Diabetes mellitus, malnutrition, and renal failure lead to metabolic acidosis because of the increasing acids in the body. Options 1, 2, and 5 are respiratory problems, not metabolic, and result in either respiratory acidosis or respiratory alkalosis.
The Nurse Practice Act is a series of statutes enacted by the federal government in order to regulate the practice of nursing. The Nurse Practice Act is a series of statutes enacted by each state legislature in order to regulate the practice of nursing in that particular state. All the other statements are true and correct.
Informing your supervisor that you cannot assume nursing duties until sufficient preparation for the specific duty has been provided. It is the nurse’s responsibility to inform the supervisor of an inappropriate assignment. The nurse should let the supervisor know that they are uncomfortable performing these duties until they have been prepared to handle them. The supervisor may then make a more appropriate assignment. All the other statements are correct and are reasons for the Board of Nursing to take disciplinary action towards the nurse.
Assist a diabetic client on bedrest with a bed bath. This would be the MOST appropriate assignment to give to the nursing assistant with the information which has been provided. It would be inappropriate for the nursing assistant to record the vital signs in the medical chart. Since the patient requiring feeding had a stroke three days earlier, there is a greater risk of choking and/or aspiration of food material. The Alzheimer’s patient may be confused and may have the potential for difficulties in regards to bathroom assistance.
“This is a Vitamin K injection. Infants are deficient in Vitamin K for the first 5- 8 days of life. Vitamin K helps their blood clot. This injection is administered to all healthy newborns to help their blood clot better.” Telling the parents that the injection is for their child’s own good is an unprofessional explanation. It is untrue that infants do not feel pain. They are able to feel pain and discomfort. Telling the parents that the injection is a “necessary evil” creates a negative view of the procedure and again an unprofessional explanation. This would not be the most appropriate answer. The last response is an example of the nurse assuming that the parents do not wish for their child to receive the injection. The parents simply asked for its purpose and an explanation of why it needed to be given.
Administration of the injection within 72 hours after delivery. The injection is given to an Rh-negative mother to prevent isoimmunization from the possibility of exposure to Rh-positive blood. Exposure can occur not only through delivery of an Rh-positive infant but also by transfusion, amniocentesis, chorionic villus sampling, abdominal injury or trauma, bleeding during pregnancy, and termination of a pregnancy. The injection should never be administered to an Rh-positive patient, a patient with an elevated temperature, or a patient with a history of an allergic reaction to preparations containing human immunoglobulins. The injection should never be administered to a newborn.
"This stage occurs in adolescence (12-20 years), when the adolescent is confused about who he is. An example is when the adolescent obtains a tattoo, which he feels shows the world who he really is.” The school age child (6-12 years) is in the stage or psychosocial crisis of “industry vs. inferiority”. In early adulthood (20-35 years), they are experiencing the “intimacy vs. isolation” stage or crisis. In middle adulthood (35-65 years), they are experiencing the “generativity vs. stagnation” stage or crisis.
The nurse should pay close attention to swelling in the client with preeclampsia. Facial swelling indicates that the client’s condition is worsening and blood pressure will be increased. Answer B is not related to the question; therefore, it is incorrect. Answer C is incorrect because ankle edema is expected in pregnancy. Diminished reflexes are associated with the use of magnesium sulfate, which is the treatment of preeclampsia; therefore, answer D is incorrect.
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NCLEX Select All That Apply #10
