Question

A telemetry nurse has received bedside report on several clients. Which client is at the greatest risk for hypernatremia?

Answer 1

Correct Answers:

A client with diabetes insipidus who is unresponsive

Rationale :

💧Diabetes insipidus causes excessive water loss due to insufficient antidiuretic hormone (ADH), leading to hypernatremia as sodium becomes concentrated in the blood.

🧠An unresponsive client is at greater risk because they cannot drink water to compensate for the dehydration caused by polyuria.

⚠️Hypernatremia manifests with neurological changes such as confusion, seizures, and coma due to cellular dehydration.

💊In contrast, clients with CHF or adrenal insufficiency usually experience hyponatremia due to fluid retention or hormone imbalance, not hypernatremia.

📌Core Message

Hypernatremia most often results from water loss in conditions like diabetes insipidus, especially in clients unable to replace fluids.

Answer 2

Correct Answers:

Stridor

Rationale :

💁‍♂️Stridor is a high-pitched sound indicating airway obstruction, a medical emergency that can occur from anaphylaxis during antibiotic infusion.

⚠️Airway compromise is always the priority because it threatens oxygenation and ventilation.

💉Antibiotic infusions, particularly penicillin and sulfa drugs, can trigger severe allergic reactions.

🚨Immediate intervention with epinephrine and airway support is necessary to prevent respiratory arrest.

📌Core Message

Stridor during antibiotic infusion indicates airway obstruction from anaphylaxis and requires immediate action.

Answer 3

Correct Answers

Blank 1 Correct Option: carbonic acid–bicarbonate system
Blank 2 Correct Option: helps regulate pH by neutralizing excess acids or bases

Rationale :

🧪The carbonic acid–bicarbonate system is the body’s main chemical buffer that maintains acid–base homeostasis in extracellular fluid.

💁‍♂️It operates through a reversible reaction where carbonic acid (H₂CO₃) dissociates into bicarbonate (HCO₃⁻) and hydrogen ions to stabilize blood pH.

⚖️This system neutralizes excess acids or bases, preventing major shifts in pH that could disrupt cellular enzyme activity.

🌬️Both the lungs and kidneys regulate this system—lungs control carbonic acid via CO₂ removal, and kidneys adjust bicarbonate concentration for long-term balance.

📌Core Message

The carbonic acid–bicarbonate system maintains acid–base balance by neutralizing excess acids or bases through respiratory and renal regulation.

Answer 4

Correct Answers:

Fully compensated metabolic acidosis

Rationale :

🧪A pH of 7.36 indicates near-normal levels, suggesting full compensation.

💨A low PaCO₂ (32 mmHg) shows respiratory alkalosis compensation through increased ventilation to eliminate acid.

💧A low HCO₃⁻ (18 mEq/L) confirms metabolic acidosis as the primary disorder.

💁‍♂️Because pH is within normal limits but both CO₂ and HCO₃⁻ are abnormal, full compensation has occurred.

📌Core Message

Fully compensated metabolic acidosis occurs when respiratory compensation restores normal pH despite low bicarbonate.

Answer 5

Correct Answers:

Blood pressure of 88/52 mmHg

Rationale :

💧Fluid volume deficit leads to hypovolemia, which can cause hypotension and poor tissue perfusion.

💁‍♂️A BP of 88/52 mmHg indicates shock risk, requiring immediate intervention to restore circulatory stability.

🧠Low perfusion pressure threatens organ oxygenation, especially in the brain and kidneys.

⚠️While tachycardia and mild hypernatremia may occur, hypotension is the most critical finding needing urgent correction.

📌Core Message

Hypotension in fluid volume deficit signals impaired perfusion and requires immediate fluid resuscitation.

Answer 6

Correct Answers:

83

Rationale :

📏To calculate: (250 mL × 20 gtt/mL) ÷ 60 min = 83 gtt/min.

💉The drop factor (20 gtt/mL) converts mL/hr into drops per minute for manual IV administration.

⚙️This ensures the infusion runs at the correct therapeutic rate to deliver 800 mg gentamicin safely over 1 hour.

⚠️An incorrect flow rate could result in under- or overdosing, affecting drug efficacy and safety.

📌Core Message

The correct infusion rate for gentamicin 250 mL over 1 hour with a 20 gtt/mL set is 83 gtt/min.

Answer 7

Correct Answers:

Decreased respiratory rate

Rationale :

💁‍♂️In respiratory acidosis, CO₂ retention causes hypoventilation and increased blood acidity.

⚠️A decreased respiratory rate means worsening CO₂ retention, leading to severe acidosis and hypoxia.

🧠Symptoms progress from lethargy to confusion to coma if not corrected promptly.

💨Treatment aims to improve ventilation and remove CO₂; declining respiratory effort indicates therapy failure.

📌Core Message

A decreased respiratory rate in respiratory acidosis signals worsening CO₂ retention and requires urgent intervention.

Answer 8

Correct Answers:

Absent breath sounds on the left side

Rationale :

💁‍♂️Absent breath sounds post-thoracentesis may indicate a pneumothorax, a life-threatening complication.

⚠️Air can enter the pleural space, collapsing the lung and impairing gas exchange.

🧠The nurse should immediately assess respiratory distress and notify the provider for chest tube placement.

📉Pain and drainage are expected; however, absent sounds signal lung collapse, the priority concern.

📌Core Message

Absent breath sounds after thoracentesis indicate possible pneumothorax and require urgent response.

Answer 9

Correct Answers:

Active artificial immunity

Rationale :

💉Vaccines such as the pertussis vaccine stimulate the body to produce its own antibodies without actual infection.

🧠This type of protection is termed active artificial immunity because it’s acquired through immunization.

🛡️It provides long-term defense by creating memory cells that recognize the pathogen in future exposures.

🧬In contrast, passive immunity provides temporary protection through antibody transfer rather than self-production.

📌Core Message

The pertussis vaccine provides active artificial immunity by stimulating the body’s antibody production through vaccination.

Answer 10

Correct Answers:

Fully compensated respiratory acidosis

Rationale :

💁‍♂️The pH of 7.35 is on the lower end of normal, indicating the body has compensated for acid retention.

💨The PaCO₂ of 50 mmHg shows CO₂ retention, a hallmark of respiratory acidosis.

🧪The HCO₃ of 30 mEq/L is elevated, demonstrating renal compensation through bicarbonate retention to neutralize acid.

🧠This ABG pattern is typical for COPD clients, where the kidneys adjust bicarbonate to balance chronic CO₂ elevation.

📌Core Message

COPD clients often show fully compensated respiratory acidosis with high CO₂ and high HCO₃⁻ maintaining near-normal pH.

1 :
A telemetry nurse has received bedside report on several clients. Which client is at the greatest risk for hypernatremia?

2 :
The nurse starts an intravenous infusion of antibiotics for a client with an infection. What finding requires immediate follow-up by the nurse?

3 :
Complete the following sentence by choosing from the list of options.

Correct Answers

4 :
Interpret the following
ABG: pH 7.36,
PaCO2 32 mmHg
HCO3 18 mEq/L.
Based on these ABG values, the client is experiencing:

5 :
The nurse is assessing a client with fluid volume deficit. Which finding requires immediate follow-up by the nurse?

6 :
A nurse prepares to administer gentamicin 800 mg in 250 mL of 5% dextrose in water (D5W) to be infused over 1 hour. The drop factor of the tubing is 20 gtt/mL. At what rate will the nurse set the infusion?

7 :
The nurse provides prescribed treatments to a client with respiratory acidosis. What finding indicates to the nurse that the client's condition is worsening?

8 :
The nurse assesses a client following a thoracentesis procedure to drain fluid from the left pleural space. What finding should the nurse identify as the priority?

9 :
What type of immunity does a person gain when they receive the pertussis vaccine?

10 :
A nurse is monitoring a client with COPD. The client's most recent ABG results show: pH 7.35, PaCO₂ 50 mmHg, PaO₂ 70 mmHg, HCO₃ 30 mEq/L, SaO₂ 88%. How should the nurse interpret these results?

1 : A telemetry nurse has received bedside report on several clients. Which client is at the greatest risk for hypernatremia?

2 : The nurse starts an intravenous infusion of antibiotics for a client with an infection. What finding requires immediate follow-up by the nurse?

3 : Complete the following sentence by choosing from the list of options.

Correct Answers

4 : Interpret the followingABG: pH 7.36,PaCO2 32 mmHgHCO3 18 mEq/L.Based on these ABG values, the client is experiencing:

5 : The nurse is assessing a client with fluid volume deficit. Which finding requires immediate follow-up by the nurse?

6 : A nurse prepares to administer gentamicin 800 mg in 250 mL of 5% dextrose in water (D5W) to be infused over 1 hour. The drop factor of the tubing is 20 gtt/mL. At what rate will the nurse set the infusion?

7 : The nurse provides prescribed treatments to a client with respiratory acidosis. What finding indicates to the nurse that the client's condition is worsening?

8 : The nurse assesses a client following a thoracentesis procedure to drain fluid from the left pleural space. What finding should the nurse identify as the priority?

9 : What type of immunity does a person gain when they receive the pertussis vaccine?

10 : A nurse is monitoring a client with COPD. The client's most recent ABG results show: pH 7.35, PaCO2 50 mmHg, PaO2 70 mmHg, HCO3 30 mEq/L, SaO2 88%. How should the nurse interpret these results?

1 :
A telemetry nurse has received bedside report on several clients. Which client is at the greatest risk for hypernatremia?

2 :
The nurse starts an intravenous infusion of antibiotics for a client with an infection. What finding requires immediate follow-up by the nurse?

3 :
Complete the following sentence by choosing from the list of options.

4 :
Interpret the following
ABG: pH 7.36,
PaCO2 32 mmHg
HCO3 18 mEq/L.
Based on these ABG values, the client is experiencing:

5 :
The nurse is assessing a client with fluid volume deficit. Which finding requires immediate follow-up by the nurse?

6 :
A nurse prepares to administer gentamicin 800 mg in 250 mL of 5% dextrose in water (D5W) to be infused over 1 hour. The drop factor of the tubing is 20 gtt/mL. At what rate will the nurse set the infusion?

7 :
The nurse provides prescribed treatments to a client with respiratory acidosis. What finding indicates to the nurse that the client's condition is worsening?

8 :
The nurse assesses a client following a thoracentesis procedure to drain fluid from the left pleural space. What finding should the nurse identify as the priority?

9 :
What type of immunity does a person gain when they receive the pertussis vaccine?

10 :
A nurse is monitoring a client with COPD. The client's most recent ABG results show: pH 7.35, PaCO₂ 50 mmHg, PaO₂ 70 mmHg, HCO₃ 30 mEq/L, SaO₂ 88%. How should the nurse interpret these results?