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Free NCLEX-RN Exam Braindumps (page: 154)

Page 154 of 431
PDF with 862 Questions

A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:

  1. Respiratory alkalosis
  2. Respiratory acidosis
  3. Metabolic alkalosis
  4. Metabolic acidosis

Answer(s): B

Explanation:

(A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3. (D) Metabolic acidosis is determined by low pH and HCO3.



A client presents to the emergency room with cyanosis, coughing, tachypnea, and tachycardia. She has a history of asthma. Arterial blood gas values are pH 7.28, PaO2 54, PaCO2 60, and HCO3 24. The nursing assessment of arterial blood gases indicate the presence of:

  1. Respiratory alkalosis
  2. Respiratory acidosis
  3. Metabolic alkalosis
  4. Metabolic acidosis

Answer(s): B

Explanation:

(A) Respiratory alkalosis is determined by elevated pH and low PaCO2. (B) Respiratory acidosis is determined by low pH and elevated PaCO2. (C) Metabolic alkalosis is determined by elevated pH and HCO3. (D) Metabolic acidosis is determined by low pH and HCO3.



A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?

  1. Fluid volume deficit secondary to alteration in skin integrity
  2. Alteration in comfort secondary to alteration in skin integrity
  3. Alteration in sensation secondary to third-degree burn
  4. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity

Answer(s): D

Explanation:

(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48­72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in
poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.



A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours' postburn?

  1. Fluid volume deficit secondary to alteration in skin integrity
  2. Alteration in comfort secondary to alteration in skin integrity
  3. Alteration in sensation secondary to third-degree burn
  4. Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity

Answer(s): D

Explanation:

(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client's hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48­72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client's airway status could result in
poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.



Page 154 of 431



Post your Comments and Discuss NCLEX NCLEX-RN exam with other Community members:

Naveen Ahlam commented on November 29, 2024
Great stuff
Anonymous
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Isadora Guimarães commented on November 10, 2024
Very good to study
UNITED STATES
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Marydee commented on April 02, 2020
Just purchased, will see if it is the real deal. Will give a further update later!
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