A child has acute kidney injury (AKI). Which primary acid-base balance does the nurse assess the child for?
A.
Metabolic acidosis
B.
Metabolic alkalosis
C.
Respiratory acidosis
D.
Respiratory alkalosis
ANS: A
In AKI there is insufficient hydrogen ion excretion and poor bicarbonate reabsorption, leading to metabolic acidosis.
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An elderly patient in the ICU with acute respiratory distress syndrome (ARDS) has developed sepsis. Which of the following interventions should the nurse implement to address the sepsis and its symptoms? Select all that apply
A) Antibiotic therapy B) Elevating head of the bed 30 to 45 degrees C) Weaning protocol D) Daily sedation withholding E) Steroid administration F) Activated protein C
The nurse is admitting a client of the Muslim faith during the holy month of Ramadan. The client tells the nurse that he must fast during this time. Which response by the nurse is the most appropriate?
1. "What can we do to accommodate your needs during your stay here?" 2. "I will let your healthcare provider know that you need to be discharged." 3. "Fasting is harmful to your body." 4. "You must have food during times of illness."
The laboring client's fetal heart rate baseline is 120 beats per minute. Accelerations are present to 135 beats/min. During contractions, the fetal heart rate gradually slows to 110, and is at 120 by the end of the contraction
What nursing action is best? 1. Document the fetal heart rate. 2. Apply oxygen via mask at 10 liters. 3. Prepare for imminent delivery. 4. Assist the client into Fowler's position.
During the assessment interview, the client is quiet and answers questions only minimally. What action should the nurse take in regard to this apparent unwillingness to share information?
1. Document that the client is not cooperative. 2. Consider any cultural implications of these actions. 3. Assume that the client has something to hide. 4. Ask another nurse to sit in on the next interview attempt.