A nurse evaluates a client's arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3- 22 mEq/L. Which intervention should the nurse implement first?
a. Assess the airway.
b. Administer prescribed bronchodilators.
c. Provide oxygen.
d. Administer prescribed mucolytics.
ANS: A
All interventions are important for clients with respiratory acidosis; this is indicated by the ABGs. However, the priority is assessing and maintaining an airway. Without a patent airway, other interventions will not be helpful.
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A client with a history of frequent outbursts and fighting has been receiving treatment to help control emotions and anger. Which client statement shows that treatment has been effective?
A) "My brothers are the only ones I can fight with and not get in trouble." B) "There are other ways to deal with anger, and I will use them instead of fighting." C) "Hitting people is only justified sometimes." D) "As long as my mother doesn't hit me first, I will not hit her."
An older patient with chronic health problems does not want to be admitted to a nursing home for continued care. What can the nurse explain to the patient about nursing homes today? Standard Text: Select all that apply
1. Nursing homes are for short-term stays. 2. Nursing homes help the patient with activities of daily living. 3. Nursing homes are being replaced with community-based services. 4. Nurses in nursing homes provide at least 5 hours of care to each patient each day. 5. Nursing homes help with bathing, toileting, meals, and medication administration,
Two patients on your unit have returned from right knee arthroscopies. Patient A is reporting pain of an eight to nine on a zero-to-ten pain scale. Patient B is reporting a pain level of three to four on the same pain scale
What may provide a rationale for the different perceptions of pain? A) Endorphin levels may vary between patients, affecting the perception of pain. B) One of the patients is exaggerating her sense of pain. C) The patients are likely experiencing a variance in vasoconstriction. D) One of the patients may be experiencing opiate tolerance.
The nurse is providing instruction to a group of patients who are planning to participate in an athletic triathlon. Each member of the group has been diagnosed with either diabetes mellitus type 1 or type 2
A member of the group asks, "If we each follow our usual daily diabetic control routine, which diabetic complication is most likely to occur during this event?" What is the nurse's best answer? 1. Diabetic ketoacidosis 2. Hypoglycemia 3. Hyperosmolar hyperglycemic state 4. Impaired glucose tolerance