A nurse is reviewing the ABG results of a client who the provider suspects has
metabolic acidosis. What would thenurse expect to see
pH below 7.35
A pt is experiencing SOB, fatigue, JVD, the nurse auscultates a third heart sound
(S3), what should the nurse anticipate as the cause of these s/s
HF
A nurse is administering potassium chloride elixer 40mEq divided into 2 equal doses
every 12 hours, available is 6.7mEq/5mL. How many mL should the nurse administer
per dose?
30mL
A nurse is caring for a pt in the ED who was just admittedwith chest pain, possible acute
coronary syndrome. What should the nurse do first?
Administer sublingual nitroglycerin
(treat chest pain to reduce cardiac tissue damage)
A nurse is caring for pt who is experiencing ventricular tachycardia with a pulse, the
RRT is at the bedside. What elctrialintervention should be used to correct this dysrhythmia?
Synchronized cardioversion
(tx for afib, SVT, and v tach with a pulse)
A nurse is caring for an adult pt who is experiencingdelayed wound healing, which of
the following interventions should the nurse take?
Monitor serum albumin levels and notify provider if below3.5g/dL
(lack of protein increases the risk for a delay in woundhealing and infection)
A nurse is teaching a client who has pre-dialysis ESKDabout diet, what should be
included?
Reduce intake of foods high in potassium
(potassium clearance is impaired in ESKD)
A nurse is caring for a client who has T1DM, the nurse misread the client's morning
BG level as 210mg/dL, instead of 120mg/dL and administered the insulin dose
appropriate for a reading over 200mg/dL before the client's breakfast, what action is
, the nurse's priority?
Monitor the client for hypoglycemia
A nurse is planning care for a pt who has a new diagnosisof DI, which of the
following interventions should the nurse include in the plan of care?
Check urine specific gravity
A nurse is caring for a pt admitted with wheezing and coughing due to an allergic
reaction to a newly prescribedmedication, what medication should be administered
first?
Albuterol 3mL via nebulizer
A nurse is caring for a female client in the ED who reportsSOB and pain in the lung
area, she states that she startedtaking BC pills 3 weeks ago and that she smokes, her
heart rate is 110/min, RR 40/min, and BP 140/80, her ABGs are pH 7.50, PaCO2 29,
PaO2 60, HCO3 20, SaO2 86%, what is the priority of nursing interventionsadminister
oxygen via face mask
A nurse is caring for a pt following repair of a fracture,what finding should alert the
nurse that the pt is experiencing compartment syndrome?
Unrelieved pain, pallor, pulselessness, numbness, pins and needles sensation,
swelling, tightness of the effectedextremity
A nurse is administering a tap water enema to a pt who isconstipated, during the
administration of the enema, the client states he is having abdominal cramps, what
action should the nurse take to relieve the client's comfort
Lower the height of the solution container
A pt is diagnosed with left homonymous hemianopsia following a stroke, what action
should the nurse take?
Place the client’s bedside table on the right side of thebed
A nurse is caring for a pt who is at risk for shock, what finding is the earliest
indicator that this complication isdeveloping?
Narrowing pulse pressure
A nurse is assessing a client who has hypokalemia as a result of n/v, and diarrhea,
what finding should the nurseexpect
Weak, irregular pulse