Data collection findings for a patient involved in a motor vehicle accident include pale mucous membranes, diaphoresis, confusion, blood pressure 88/48 mm Hg, irregular heart rhythm, and metabolic acidosis
Which of these does the nurse recognize as the likely cause of this acidosis?
a. Inadequate ventilation
b. Hyperventilation
c. Aerobic metabolism
d. Anaerobic metabolism
ANS: D
D. When cells are deprived of oxygen, they shift to anaerobic metabolism, resulting in the production of lactic acid. Unless the lactic acid is removed from the bloodstream, the blood will become increasingly acidic, resulting in metabolic acidosis. A. Inadequate ventilation leads to respiratory acidosis as CO2 levels rise. B. Hyperventilation leads to respiratory alkalosis as CO2 levels decrease. C. Aerobic metabolism is normal.
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Which of the following 66-year-old clients who needs skilled nursing care would be eligible for home health care reimbursement by Medicare?
a. A client who always worked for the state and enjoys going to the neighborhood coffee shop on a daily basis b. A client who needs his wounds cared for every day, including weekends, and needs the nurse to visit at 8 AM every day c. A client who is a loner and has no one to assist him except for the home care agency d. A client who is homebound and has a very strong support system e. A client who is an illegal immigrant who has lived in the United States for 25 years but begged the nurse not to tell
The nurse finds that an infant has stronger pulses in the upper extremities than in the lower extremities and higher blood pressure readings in the arms than in the legs. This could be indicative of which heart defect?
1. Patent ductus arteriosus 2. Atrial septal defect 3. Transposition of the great vessels 4. Coarctation of the aorta
The client with heart failure has been prescribed intravenous nitroglycerin and furosemide (Lasix) for pulmonary edema. Which is the priority nursing intervention?
a. Insert an indwelling urinary catheter. b. Monitor the client's blood pressure. c. Place the nitroglycerin under the client's tongue. d. Monitor the client's serum glucose level.
Which term describes how the body affects drug activity?
a. Drug potency b. Pharmacodynamics c. Therapeutic effect d. Pharmacokinetics