NCSBNhON-LINEhREVIEW
1. Ah clienth hash beenh hospitalizedh afterh anh automobileh accident.h Ah fullh legh casth wash appliedh inh thehe
mergencyhroom.h Thehmosthimportanthreasonhforhthehnursehtohelevatehthehcastedhleghishto
A) Promotehthehclient'shcomfort
B) Reducehthehdryinghtime
C) Decreasehirritationhtohthehskin D)h Improvehvenoushreturn
D:hImprovehvenoushreturn.hElevatinghthehleghbothhimproveshvenoushreturnhandhreduceshswelling.hCl
ienthcomforth willhbehimprovedhashwell.
2. Theh nurseh ish reviewingh withh ah clienth howh toh collecth ah cleanh catchh urineh specimen.h Whath ish theha
ppropriatehsequencehtohteachhthehclient?
A) Cleanhthehmeatus,hbeginhvoiding,hthenhcatchhurinehstream
B) Voidhahlittle,hcleanhthehmeatus,hthenhcollecthspecimen
C) Cleanhthehmeatus,hthenhurinatehintohcontainer
D) Voidhcontinuouslyhandhcatchhsomehofhthehurine
A:hCleanhthehmeatus,hbeginhvoiding,hthenhcatchhurinehstream.hAhcleanhcatchhurinehishdifficulthtohobta
inhandhrequireshclearhdirections.hInstructinghthehclienthtohcarefullyhcleanhthehmeatus,hthenhvoidhnatur
allyhwithhahsteadyhstreamhpreventshsurfacehbacteriahfromhcontaminatinghthehurinehspecimen.hAshstar
tinghandhstoppinghflowhcanhbehdifficult,honcehthehclienthbeginshvoidinghit’shbesthtohjusthsliphthehconta
inerhintohthehstream.hOtherhresponseshdohnothreflecthcorrecthtechnique
3. Followinghchange-of-shifthreporthonhanhorthopedichunit,hwhichhclienthshouldhthehnursehseehfirst?
A) 16hyear-oldhwhohhadhanhopenhreductionhofhahfracturedhwristh10hhourshago
B) 20hyear-oldhinhskeletalhtractionhforh2hweekshsincehahmotorhcyclehaccident
C) 72hyear-oldhrecoveringhfromhsurgeryhafterhahhiphreplacementh2hhourshago
D) 75hyear-oldhwhohishinhskinhtractionhpriorhtohplannedhhiphpinninghsurgery.
C:h Lookhforhthehclienthwhohhashthehmosthimminenthriskshandhacutehvulnerability.hThehclienthwhohre
turnedhfromhsurgeryh2hhourshagohishathriskhforhlifehthreateninghhemorrhagehandhshouldhbehseenhfirst.h
Theh16hyear-oldhshouldhbehseenhnexthbecausehithishstillhthehfirsthpost-ophday.hTheh75hyear-
oldhishpotentiallyhvulnerablehtohage-
relatedhphysicalhandhcognitivehconsequenceshinhskinhtractionhshouldh beh seenh next.h Theh clienth whoh
can
post-injury.
h safelyh beh seenh lasth ish theh 20h year-oldh whoh ish 2h weeks
4. AhclienthwithhGuillainhBarrehishinhahnonresponsivehstate,hyethvitalhsignsharehstablehandhbreathinghishi
ndependent.hWhathshouldhthehnursehdocumenthtohmosthaccuratelyhdescribehthehclient'shcondition?
A) Comatose,hbreathinghunlabored
B) GlascowhComahScaleh8,hrespirationshregular
C) Appearshtohbehsleeping,hvitalhsignshstable
D) GlascowhComahScaleh13,hnohventilatorhrequired
B:hGlascowhComahScaleh8,hrespirationshregular.hThehGlascowhComahScalehprovideshahstandardhrefe
rencehforhassessinghorhmonitoringhlevelhofhconsciousness.hAnyhscorehlesshthanh13hindicateshahneurol
ogicalh impairment.h Usingh theh termh comatoseh providesh tooh muchh roomh forh interpretation
andhishnothveryhprecise.
5. Whenhcaringhforhahclienthreceivinghwarfarinhsodiumh(Coumadin),hwhichhlabhtesthwouldhthehnursehm
onitorhtohdeterminehtherapeutichresponsehtohthehdrug?
A) Bleedinghtime
B) Coagulationhtime
C) Prothrombinhtime
D) Partialhthromboplastinhtime
C:hProthrombinhtime.hCoumadinhishorderedhdaily,hbasedhonhthehclient''shprothrombinhtimeh(PT).hThi
,6. Ahclienthwithhmoderatehpersistenthasthmahishadmittedhforhahminorhsurgicalhprocedure.hOnhadmissionht
hehpeakhflowhmeterhishmeasuredhath480hliters/minute.hPost-
operativelyhthehclienthishcomplaininghofhchesthtightness.hThehpeakhflowhhashdroppedhtoh200hliters/m
inute.hWhathshouldhthehnursehdohfirst?
A) Notifyhbothhthehsurgeonhandhprovider
B) Administerhthehprnhdosehofhalbuterol
C) Applyhoxygenhath2hlitershperhnasalhcannula
D) Repeaththehpeakhflowhreadinghinh30hminutes
B:hAdministerhthehprnhdosehofhalbuterol.hPeakhflowhmonitoringhduringhexacerbationshofhasthmahishr
ecommendedhforhclientshwithhmoderate-to-
severehpersistenthasthmahtohdeterminehthehseverityhofhthehexacerbationhandhtohguidehthehtreatment.h
Ahpeakhflowhreadinghofhlesshthanh50%hofhthehclient''shbaselineh readingh ish ah medicalh alerth conditio
nimmediately.
h andh ah short-actingh beta-agonisth musth beh taken
7. Ahclienthhadh20hmghofhLasixh(furosemide)hPOhath10hAM.hWhichhwouldhbehessentialhforhthehnursehtohin
cludehaththehchangehofhshifthreport?
A) Thehclienthlosth2hpoundshinh24hhours
B) Thehclient’shpotassiumhlevelhish4hmEq/liter.
C) Thehclient’shurinehoutputhwash1500hcchinh5hhours
D) ThehclienthishtohreceivehanotherhdosehofhLasixhath10hPM
C:h Theh client’sh urineh outputh wash 1500h cch inh 5h hours.h Althoughh allh ofh theseh mayh beh correcthinfor
mationhtohincludehinhreport,hthehessentialhpiecehwouldhbehthehurinehoutput.
8. AhclienthhashbeenhtentativelyhdiagnosedhwithhGraves'h diseaseh(hyperthyroidism).hWhichhofhtheseh fin
dingshnotedhonhthehinitialhnursinghassessmenthrequireshquickhinterventionhbyhthehnurse?
A) ahreporthofh10hpoundshweighthlosshinhthehlasthmonth
B) ahcommenthbyhthehclienth"Ihjusthcan'thsithstill."
C) thehappearancehofheyeballshthathappearhtoh"pop"houthofhthehclient'sheyehsockets
D) ahreporthofhthehsuddenhonsethofhirritabilityhinhthehpasth2hweeks
C:hthehappearancehofheyeballshthathappearhtoh"pop"houthofhthehclient''sheyehsockets.hExophthalmosho
rhprotrudingheyeballshishahdistinctivehcharacteristichofhGraves''hDisease.hIthcanhresulthinhcornealhabra
sionsh withh severeh eyeh painh orh damageh whenh theh eyelidh ish unableh toh blinkh downh overh the
protrudingheyeball.hEyehdropshorhointmenthmayhbehneeded.
9. Theh nurseh hash performedh theh initialh assessmentsh ofh 4h clientsh admittedh withh anh acuteh episodeh ofha
sthma.hWhichhassessmenthfindinghwouldhcausehthehnursehtohcallhthehproviderhimmediately?
A) prolongedhinspirationhwithheachhbreath
B) expiratoryhwheezeshthatharehsuddenlyhabsenthinh1hlobe
C) expectorationhofhlargehamountshofhpurulenthmucous
D) appearancehofhthehusehofhabdominalhmuscleshforhbreathing
B:hexpiratoryhwheezeshthatharehsuddenlyhabsenthinh1hlobe.hAcutehasthmahishcharacterizedhbyhexpirat
oryhwheezeshcausedhbyhobstructionhofhthehairways.hWheezesharehahhighhpitchedhmusicalhsoundshpro
ducedhbyhairhmovinghthroughhnarrowedhairways.hClientshoftenhassociatehwheezeshwithhthehfeelingho
fhtightnesshinhthehchest.hHowever,hsuddenhcessationhofhwheezinghishanhominoushorhbadhsignhthathindi
cateshanhemergencyh--hthehsmallhairwaysharehnowhcollapsed.
10. Duringhthehinitialhhomehvisit,hahnursehishdiscussinghthehcarehofhahclienthnewlyhdiagnosedhwithhAlzhei
mer'shdiseasehwithhfamilyhmembers.hWhichhofhthesehinterventionshwouldhbeh mosthhelpfulhaththishti
me?
, D) suggesthcommunicationhstrategies
D:hsuggesthcommunicationhstrategies.hAlzheimer''shdisease,hahprogressivehchronichillness,hgreatlyhc
hallengeshcaregivers.hThehnursehcanhbehofhgreatesthassistancehinhhelpinghthehfamilyhtohusehcommuni
cationhstrategieshtohenhancehtheirhabilityhtohrelatehtohthehclient.hByhusehofhselecthverbalhandh nonverb
alh communicationh strategiesh theh familyh canh besth supporth theh client’sh strengthsh and
copehwithhanyhaberranthbehavior.
11. Anh80hyear-
oldhclienthadmittedhwithhahdiagnosishofhpossiblehcerebralhvascularhaccidenthhashhadhahbloodhpressurehfro
mh160/100hto
180/110hoverhthehpasth2hhours.hThehnursehhashalsohnotedhincreasedhlethargy.hWhichhassessmenth fin
dinghshouldhthehnursehreporthimmediatelyhtohthehprovider?
A) Slurredhspeech
B) Incontinence
C) MusclehweaknessD)h Rapidhpulse
A:h Slurredh speech.h Changesh inh speechh patternsh andh levelh ofh conscioush canh beh indicatorsh ofhco
ntinuedh intracranialh bleedingh orh extensionh ofh theh stroke.h Furtherh diagnostich testingh mayh be
indicated.
12. Ahschool-
agedhchildhhashhadhahlonghlegh(hiphtohankle)hsynthetichcasthappliedh4hhourshago.hWhichhstatementhfr
omhthehparenthindicateshthathteachinghhashbeenhinadequate?
A) "Ihwillhkeephthehcasthuncoveredhforhthehnexthdayhtohpreventhburninghofhthehskin."
B) "Ihcanhapplyhanhicehpackhoverhthehareahtohrelievehitchinghinsidehthehcast."
C) "Thehcasthshouldhbehproppedhonhathleasth2hpillowshwhenhmyhchildhishlyinghdown."
D) "IhthinkhIhrememberhthathmyhchildhshouldhnothstandhuntilhafterh72hhours."
D:h"IhthinkhIhrememberhthathmyhchildhshouldhnothstandhuntilhafterh72hhours.".hSynthetichcastshwillhty
picallyhsethuphinh30hminuteshandhdryhinhahfewhhours.hThus,hthehclienthmayhstandhwithinhthehinitialh24h
hours.hWithhplasterhcasts,hthehsethuphandhdryinghtime,hespeciallyhinhahlonghleghcasthwhichhishthickerht
hanhanharmhcast,hcanhtakehuphtoh72hhours.hBothhtypeshofhcastshgivehoffhahlothofhheathwhenhdryinghandh
ithishpreferablehtohkeephthehcasthuncoveredhforhthehfirsth24hhours.hClientshmayh complainhofhahchillhfr
omhthehwethcasthandhthereforehcanhsimplyhbehcoveredhlightlyhwithhahsheethor
blanket.hApplyinghicehishahsafehmethodhofhrelievinghthehitching.
13. Whichhbloodhserumhfindinghinhahclienthwithhdiabetichketoacidosishalertshthehnursehthathimmediateha
ctionhishrequired?
A) pHhbelowh7.3
B) Potassiumhofh5.0
C) HCThofh60
D) PahO2hofh79%
C:h HCTh ofh 60.h Thish highh hematocrith ish indicativeh ofh severeh dehydrationh whichh requiresh priority
attentionhinhdiabetichketoacidosis.hWithouthsufficienthhydration,hallhsystemshofhthehbodyharehathrisk
forhhypoxiahfromhahlackhofhorhsluggishhcirculation.h Inhthehabsencehofhinsulin,hwhichhfacilitateshthe
transporth ofh glucoseh intoh theh cell,h theh bodyh breaksh downh fatsh andh proteinsh toh supplyh energy
ketones,h ah by-producth ofh fath metabolism.h Theseh accumulateh causingh metabolich acidosish (pHh <
7.3),h whichh wouldhbeh thehsecondh concernh forh thish client.hTheh potassiumh andh PaO2h levelsh areh near
, aluation.hWhichhofhthehfollowinghwouldhbehnecessaryhforhpreparinghthehclienthforhthishtest?
1. Ah clienth hash beenh hospitalizedh afterh anh automobileh accident.h Ah fullh legh casth wash appliedh inh thehe
mergencyhroom.h Thehmosthimportanthreasonhforhthehnursehtohelevatehthehcastedhleghishto
A) Promotehthehclient'shcomfort
B) Reducehthehdryinghtime
C) Decreasehirritationhtohthehskin D)h Improvehvenoushreturn
D:hImprovehvenoushreturn.hElevatinghthehleghbothhimproveshvenoushreturnhandhreduceshswelling.hCl
ienthcomforth willhbehimprovedhashwell.
2. Theh nurseh ish reviewingh withh ah clienth howh toh collecth ah cleanh catchh urineh specimen.h Whath ish theha
ppropriatehsequencehtohteachhthehclient?
A) Cleanhthehmeatus,hbeginhvoiding,hthenhcatchhurinehstream
B) Voidhahlittle,hcleanhthehmeatus,hthenhcollecthspecimen
C) Cleanhthehmeatus,hthenhurinatehintohcontainer
D) Voidhcontinuouslyhandhcatchhsomehofhthehurine
A:hCleanhthehmeatus,hbeginhvoiding,hthenhcatchhurinehstream.hAhcleanhcatchhurinehishdifficulthtohobta
inhandhrequireshclearhdirections.hInstructinghthehclienthtohcarefullyhcleanhthehmeatus,hthenhvoidhnatur
allyhwithhahsteadyhstreamhpreventshsurfacehbacteriahfromhcontaminatinghthehurinehspecimen.hAshstar
tinghandhstoppinghflowhcanhbehdifficult,honcehthehclienthbeginshvoidinghit’shbesthtohjusthsliphthehconta
inerhintohthehstream.hOtherhresponseshdohnothreflecthcorrecthtechnique
3. Followinghchange-of-shifthreporthonhanhorthopedichunit,hwhichhclienthshouldhthehnursehseehfirst?
A) 16hyear-oldhwhohhadhanhopenhreductionhofhahfracturedhwristh10hhourshago
B) 20hyear-oldhinhskeletalhtractionhforh2hweekshsincehahmotorhcyclehaccident
C) 72hyear-oldhrecoveringhfromhsurgeryhafterhahhiphreplacementh2hhourshago
D) 75hyear-oldhwhohishinhskinhtractionhpriorhtohplannedhhiphpinninghsurgery.
C:h Lookhforhthehclienthwhohhashthehmosthimminenthriskshandhacutehvulnerability.hThehclienthwhohre
turnedhfromhsurgeryh2hhourshagohishathriskhforhlifehthreateninghhemorrhagehandhshouldhbehseenhfirst.h
Theh16hyear-oldhshouldhbehseenhnexthbecausehithishstillhthehfirsthpost-ophday.hTheh75hyear-
oldhishpotentiallyhvulnerablehtohage-
relatedhphysicalhandhcognitivehconsequenceshinhskinhtractionhshouldh beh seenh next.h Theh clienth whoh
can
post-injury.
h safelyh beh seenh lasth ish theh 20h year-oldh whoh ish 2h weeks
4. AhclienthwithhGuillainhBarrehishinhahnonresponsivehstate,hyethvitalhsignsharehstablehandhbreathinghishi
ndependent.hWhathshouldhthehnursehdocumenthtohmosthaccuratelyhdescribehthehclient'shcondition?
A) Comatose,hbreathinghunlabored
B) GlascowhComahScaleh8,hrespirationshregular
C) Appearshtohbehsleeping,hvitalhsignshstable
D) GlascowhComahScaleh13,hnohventilatorhrequired
B:hGlascowhComahScaleh8,hrespirationshregular.hThehGlascowhComahScalehprovideshahstandardhrefe
rencehforhassessinghorhmonitoringhlevelhofhconsciousness.hAnyhscorehlesshthanh13hindicateshahneurol
ogicalh impairment.h Usingh theh termh comatoseh providesh tooh muchh roomh forh interpretation
andhishnothveryhprecise.
5. Whenhcaringhforhahclienthreceivinghwarfarinhsodiumh(Coumadin),hwhichhlabhtesthwouldhthehnursehm
onitorhtohdeterminehtherapeutichresponsehtohthehdrug?
A) Bleedinghtime
B) Coagulationhtime
C) Prothrombinhtime
D) Partialhthromboplastinhtime
C:hProthrombinhtime.hCoumadinhishorderedhdaily,hbasedhonhthehclient''shprothrombinhtimeh(PT).hThi
,6. Ahclienthwithhmoderatehpersistenthasthmahishadmittedhforhahminorhsurgicalhprocedure.hOnhadmissionht
hehpeakhflowhmeterhishmeasuredhath480hliters/minute.hPost-
operativelyhthehclienthishcomplaininghofhchesthtightness.hThehpeakhflowhhashdroppedhtoh200hliters/m
inute.hWhathshouldhthehnursehdohfirst?
A) Notifyhbothhthehsurgeonhandhprovider
B) Administerhthehprnhdosehofhalbuterol
C) Applyhoxygenhath2hlitershperhnasalhcannula
D) Repeaththehpeakhflowhreadinghinh30hminutes
B:hAdministerhthehprnhdosehofhalbuterol.hPeakhflowhmonitoringhduringhexacerbationshofhasthmahishr
ecommendedhforhclientshwithhmoderate-to-
severehpersistenthasthmahtohdeterminehthehseverityhofhthehexacerbationhandhtohguidehthehtreatment.h
Ahpeakhflowhreadinghofhlesshthanh50%hofhthehclient''shbaselineh readingh ish ah medicalh alerth conditio
nimmediately.
h andh ah short-actingh beta-agonisth musth beh taken
7. Ahclienthhadh20hmghofhLasixh(furosemide)hPOhath10hAM.hWhichhwouldhbehessentialhforhthehnursehtohin
cludehaththehchangehofhshifthreport?
A) Thehclienthlosth2hpoundshinh24hhours
B) Thehclient’shpotassiumhlevelhish4hmEq/liter.
C) Thehclient’shurinehoutputhwash1500hcchinh5hhours
D) ThehclienthishtohreceivehanotherhdosehofhLasixhath10hPM
C:h Theh client’sh urineh outputh wash 1500h cch inh 5h hours.h Althoughh allh ofh theseh mayh beh correcthinfor
mationhtohincludehinhreport,hthehessentialhpiecehwouldhbehthehurinehoutput.
8. AhclienthhashbeenhtentativelyhdiagnosedhwithhGraves'h diseaseh(hyperthyroidism).hWhichhofhtheseh fin
dingshnotedhonhthehinitialhnursinghassessmenthrequireshquickhinterventionhbyhthehnurse?
A) ahreporthofh10hpoundshweighthlosshinhthehlasthmonth
B) ahcommenthbyhthehclienth"Ihjusthcan'thsithstill."
C) thehappearancehofheyeballshthathappearhtoh"pop"houthofhthehclient'sheyehsockets
D) ahreporthofhthehsuddenhonsethofhirritabilityhinhthehpasth2hweeks
C:hthehappearancehofheyeballshthathappearhtoh"pop"houthofhthehclient''sheyehsockets.hExophthalmosho
rhprotrudingheyeballshishahdistinctivehcharacteristichofhGraves''hDisease.hIthcanhresulthinhcornealhabra
sionsh withh severeh eyeh painh orh damageh whenh theh eyelidh ish unableh toh blinkh downh overh the
protrudingheyeball.hEyehdropshorhointmenthmayhbehneeded.
9. Theh nurseh hash performedh theh initialh assessmentsh ofh 4h clientsh admittedh withh anh acuteh episodeh ofha
sthma.hWhichhassessmenthfindinghwouldhcausehthehnursehtohcallhthehproviderhimmediately?
A) prolongedhinspirationhwithheachhbreath
B) expiratoryhwheezeshthatharehsuddenlyhabsenthinh1hlobe
C) expectorationhofhlargehamountshofhpurulenthmucous
D) appearancehofhthehusehofhabdominalhmuscleshforhbreathing
B:hexpiratoryhwheezeshthatharehsuddenlyhabsenthinh1hlobe.hAcutehasthmahishcharacterizedhbyhexpirat
oryhwheezeshcausedhbyhobstructionhofhthehairways.hWheezesharehahhighhpitchedhmusicalhsoundshpro
ducedhbyhairhmovinghthroughhnarrowedhairways.hClientshoftenhassociatehwheezeshwithhthehfeelingho
fhtightnesshinhthehchest.hHowever,hsuddenhcessationhofhwheezinghishanhominoushorhbadhsignhthathindi
cateshanhemergencyh--hthehsmallhairwaysharehnowhcollapsed.
10. Duringhthehinitialhhomehvisit,hahnursehishdiscussinghthehcarehofhahclienthnewlyhdiagnosedhwithhAlzhei
mer'shdiseasehwithhfamilyhmembers.hWhichhofhthesehinterventionshwouldhbeh mosthhelpfulhaththishti
me?
, D) suggesthcommunicationhstrategies
D:hsuggesthcommunicationhstrategies.hAlzheimer''shdisease,hahprogressivehchronichillness,hgreatlyhc
hallengeshcaregivers.hThehnursehcanhbehofhgreatesthassistancehinhhelpinghthehfamilyhtohusehcommuni
cationhstrategieshtohenhancehtheirhabilityhtohrelatehtohthehclient.hByhusehofhselecthverbalhandh nonverb
alh communicationh strategiesh theh familyh canh besth supporth theh client’sh strengthsh and
copehwithhanyhaberranthbehavior.
11. Anh80hyear-
oldhclienthadmittedhwithhahdiagnosishofhpossiblehcerebralhvascularhaccidenthhashhadhahbloodhpressurehfro
mh160/100hto
180/110hoverhthehpasth2hhours.hThehnursehhashalsohnotedhincreasedhlethargy.hWhichhassessmenth fin
dinghshouldhthehnursehreporthimmediatelyhtohthehprovider?
A) Slurredhspeech
B) Incontinence
C) MusclehweaknessD)h Rapidhpulse
A:h Slurredh speech.h Changesh inh speechh patternsh andh levelh ofh conscioush canh beh indicatorsh ofhco
ntinuedh intracranialh bleedingh orh extensionh ofh theh stroke.h Furtherh diagnostich testingh mayh be
indicated.
12. Ahschool-
agedhchildhhashhadhahlonghlegh(hiphtohankle)hsynthetichcasthappliedh4hhourshago.hWhichhstatementhfr
omhthehparenthindicateshthathteachinghhashbeenhinadequate?
A) "Ihwillhkeephthehcasthuncoveredhforhthehnexthdayhtohpreventhburninghofhthehskin."
B) "Ihcanhapplyhanhicehpackhoverhthehareahtohrelievehitchinghinsidehthehcast."
C) "Thehcasthshouldhbehproppedhonhathleasth2hpillowshwhenhmyhchildhishlyinghdown."
D) "IhthinkhIhrememberhthathmyhchildhshouldhnothstandhuntilhafterh72hhours."
D:h"IhthinkhIhrememberhthathmyhchildhshouldhnothstandhuntilhafterh72hhours.".hSynthetichcastshwillhty
picallyhsethuphinh30hminuteshandhdryhinhahfewhhours.hThus,hthehclienthmayhstandhwithinhthehinitialh24h
hours.hWithhplasterhcasts,hthehsethuphandhdryinghtime,hespeciallyhinhahlonghleghcasthwhichhishthickerht
hanhanharmhcast,hcanhtakehuphtoh72hhours.hBothhtypeshofhcastshgivehoffhahlothofhheathwhenhdryinghandh
ithishpreferablehtohkeephthehcasthuncoveredhforhthehfirsth24hhours.hClientshmayh complainhofhahchillhfr
omhthehwethcasthandhthereforehcanhsimplyhbehcoveredhlightlyhwithhahsheethor
blanket.hApplyinghicehishahsafehmethodhofhrelievinghthehitching.
13. Whichhbloodhserumhfindinghinhahclienthwithhdiabetichketoacidosishalertshthehnursehthathimmediateha
ctionhishrequired?
A) pHhbelowh7.3
B) Potassiumhofh5.0
C) HCThofh60
D) PahO2hofh79%
C:h HCTh ofh 60.h Thish highh hematocrith ish indicativeh ofh severeh dehydrationh whichh requiresh priority
attentionhinhdiabetichketoacidosis.hWithouthsufficienthhydration,hallhsystemshofhthehbodyharehathrisk
forhhypoxiahfromhahlackhofhorhsluggishhcirculation.h Inhthehabsencehofhinsulin,hwhichhfacilitateshthe
transporth ofh glucoseh intoh theh cell,h theh bodyh breaksh downh fatsh andh proteinsh toh supplyh energy
ketones,h ah by-producth ofh fath metabolism.h Theseh accumulateh causingh metabolich acidosish (pHh <
7.3),h whichh wouldhbeh thehsecondh concernh forh thish client.hTheh potassiumh andh PaO2h levelsh areh near
, aluation.hWhichhofhthehfollowinghwouldhbehnecessaryhforhpreparinghthehclienthforhthishtest?
