Question

A nurse received handoff report on four clients. Which client should the nurse recognize as being at risk for metabolic acidosis?

Answer 1

Correct Answers:

A client who has sepsis.

Rationale :

💡Sepsis leads to tissue hypo-perfusion and anaerobic metabolism, causing an accumulation of lactic acid, which results in metabolic acidosis.

🧠During sepsis, inadequate oxygen delivery to tissues forces cells to produce energy without oxygen, generating lactate as a by-product.

💊This lactic acid buildup lowers the blood pH and decreases serum bicarbonate (HCO₃⁻) levels, a hallmark of metabolic acidosis.

📚Early identification of acidosis in septic clients is essential because it indicates worsening organ perfusion and requires prompt treatment to restore oxygenation and circulation.

📌Core message

Clients with sepsis are at high risk for metabolic acidosis because lactic acid accumulates from anaerobic metabolism caused by impaired tissue perfusion.

Answer 2

Correct Answers:

Initiate continuous cardiac monitoring
0.9% sodium chloride bolus infusion at 500 mL/hr.
Titrate oxygen to SpO2 greater than 95%

Rationale :

💧This client shows severe dehydration and hypovolemic shock due to excessive fluid loss from diarrhea, as seen with low blood pressure (85/54 mmHg), tachycardia (HR 106), and poor skin turgor.

❤️The priority is to restore circulatory volume and tissue perfusion by rapidly administering 0.9% sodium chloride, which expands intravascular fluid and stabilizes blood pressure.

⚡Because the client has hypokalemia (K⁺ 3.0 mEq/L), continuous cardiac monitoring is essential to detect life-threatening dysrhythmias early and guide electrolyte management.

🌬️The oxygen saturation of 89% on room air indicates hypoxemia, so titrating oxygen to maintain SpO₂ above 95% ensures sufficient oxygen delivery to vital organs while fluid therapy is initiated.

📌Core message

The nurse must prioritize oxygen therapy, cardiac monitoring, and rapid isotonic fluid replacement to stabilize dehydration-induced hypovolemia and prevent organ failure.

Answer 3

Correct Answers:

Intercostal retractions on inspiration

Rationale :

💨Intercostal retractions occur when accessory muscles are used for breathing, indicating severe respiratory distress.

👃This finding suggests increased work of breathing and possible airway obstruction or impaired gas exchange.

⚠️Unlike mild tachycardia or anxiety, retractions are a late or severe sign of respiratory compromise, requiring immediate intervention.

⛑️Without prompt management, this client could develop respiratory failure due to ineffective ventilation.

📌Core message

Intercostal retractions signal severe respiratory distress and require immediate assessment and intervention.

Answer 4

Correct Answers

Blank 1 Correct Option: Obtain a sputum culture
Blank 2 Correct Option: Administer antibiotic therapy

Rationale :

🦠In suspected bacterial pneumonia, identifying the causative organism through a sputum culture ensures the most effective antibiotic is chosen.

💊Antibiotics must be given after collecting the specimen to avoid altering culture results and compromising diagnostic accuracy.

⚕️This sequence aligns with the nursing process—assessment before intervention.

📋Early culture and timely antibiotic administration improve treatment outcomes and reduce antimicrobial resistance.

📌Core message

Always collect a sputum culture before antibiotic therapy to ensure accurate diagnosis and effective treatment.

Answer 5

Correct Answers:

Decreased sodium level

Rationale :

💧In heart failure, worsening fluid retention causes hemodilution, lowering serum sodium concentration.

✅This hyponatremia is an indicator of worsening heart failure and poor cardiac output due to water retention.

📉A low sodium level often correlates with increased fluid overload, pulmonary congestion, and potential edema progression.

⚠️Monitoring electrolytes and weight trends helps evaluate treatment response and detect early decompensation.

📌Core message

A falling sodium level signals worsening fluid overload and deterioration in heart failure.

Answer 6

Correct Answers:

Have the client breathe into a paper bag.

Rationale :

✅The ABG shows respiratory alkalosis (pH 7.51, PaCO₂ 27 mm Hg), caused by hyperventilation during a panic attack.

😮‍💨Breathing into a paper bag allows the client to rebreathe exhaled CO₂, increasing PaCO₂ and correcting alkalosis.

💡Other interventions like oxygen therapy or bicarbonate administration are inappropriate since oxygenation and metabolic levels are normal.

📈This technique helps restore acid-base balance while calming anxiety and controlling breathing rate.

📌Core message

In respiratory alkalosis from hyperventilation, have the client rebreathe CO₂ using a paper bag to correct alkalosis.

Answer 7

Correct Answers:

Obtain blood and throat cultures.
Administer prescribed intravenous antibiotics.

Rationale :

🧫The absolute neutrophil count (325 cells/mcL) indicates severe neutropenia, placing the client at high risk for infection.

💉Cultures must be obtained before starting antibiotics to identify the pathogen and prevent false-negative results.

⚕️Once cultures are drawn, prompt initiation of IV antibiotics such as piperacillin-tazobactam is essential to prevent sepsis.

📋Both actions address the infection source directly, making them the highest priorities in neutropenic care.

📌Core message

In neutropenia, obtain cultures first, then start IV antibiotics promptly to prevent sepsis.

Answer 8

Correct Answers:

Decreased vitamin A intake

Rationale :

🥕Vitamin A is vital for epithelial tissue repair and collagen synthesis, key components of wound healing.

💡A deficiency impairs immune function and tissue regeneration, delaying wound closure and recovery.

🩹Adequate vitamin A levels support fibroblast activity and maintain mucosal and skin integrity.

📈Clients with chronic illness or poor nutrition need vitamin supplementation to promote optimal healing.

📌Core message

Low vitamin A delays wound healing by impairing epithelial repair and immune function.

Answer 9

Correct Answers:

A client with gastroenteritis

Rationale :

🤢Gastroenteritis causes loss of magnesium through prolonged vomiting and diarrhea, leading to hypomagnesemia.

💧Magnesium is essential for neuromuscular stability and enzyme function, and its depletion can cause weakness and arrhythmias.

⚡Clients with fluid loss are at risk for electrolyte imbalance, including hypokalemia and hypocalcemia.

🩺Monitoring serum magnesium levels and replacing fluids and electrolytes prevents severe complications.

📌Core message

Gastroenteritis leads to hypomagnesemia due to fluid and electrolyte loss from vomiting and diarrhea.

Answer 10

Correct Answers:

Wheezing
Chest tightness
Intercostal retractions

Rationale :

✅An asthma exacerbation causes bronchoconstriction and airway inflammation, leading to wheezing and chest tightness.

💨These symptoms reflect airflow limitation and increased effort to breathe.

⚠️Intercostal retractions are a sign of severe airway obstruction, showing that the client is struggling to ventilate effectively.

📋Early identification of these signs helps initiate bronchodilator therapy and prevent respiratory failure.

📌Core message

Wheezing, chest tightness, and retractions are key indicators of an acute asthma exacerbation and require prompt treatment.

Test	Result	Normal Range
Sodium	152 mEq/L	135–145 mEq/L
Potassium	3.0 mEq/L	3.5–5.0 mEq/L
Sodium Osmolality	305 mOsm/kg	280–295 mOsm/kg
Urine Specific Gravity	1.034	1.010–1.025

Test	Result	Normal Range
pH	7.51	7.35–7.45
PaCO₂	27 mm Hg	35–45 mm Hg
HCO₃⁻	24 mEq/L	22–26 mEq/L
PaO₂	95 mm Hg	80–100 mm Hg

1 :
A nurse received handoff report on four clients. Which client should the nurse recognize as being at risk for metabolic acidosis?

2 :
A nurse is attending to a client.

Answer Options

3 :
The nurse assesses a client admitted with stage 4 lung cancer reporting difficulty breathing. What additional finding should the nurse identify as most concerning?

4 :
A nurse is attending to a client with suspected bacterial pneumonia.

Correct Answers

5 :
The nurse provides prescribed treatments for a client with fluid volume excess related to heart failure. What finding indicates to the nurse that the client's condition is worsening?

6 :
A nurse is attending to a client.

Answer Options

7 :
A nurse is attending to a client.

Answer Options

8 :
The nurse admits a client with a non-healing wound and reviews their electronic health record. What finding in the client's chart should the nurse identify as contributing to delayed wound healing?

9 :
What client is at risk for hypomagnesemia?

10 :
A client presents to the emergency department experiencing an acute asthma exacerbation. What assessment finding(s) should the nurse expect? Select all that apply.

1 : A nurse received handoff report on four clients. Which client should the nurse recognize as being at risk for metabolic acidosis?

2 : A nurse is attending to a client.

Answer Options

3 : The nurse assesses a client admitted with stage 4 lung cancer reporting difficulty breathing. What additional finding should the nurse identify as most concerning?

4 : A nurse is attending to a client with suspected bacterial pneumonia.

Correct Answers

5 : The nurse provides prescribed treatments for a client with fluid volume excess related to heart failure. What finding indicates to the nurse that the client's condition is worsening?

6 : A nurse is attending to a client.

Answer Options

7 : A nurse is attending to a client.

Answer Options

8 : The nurse admits a client with a non-healing wound and reviews their electronic health record. What finding in the client's chart should the nurse identify as contributing to delayed wound healing?

9 : What client is at risk for hypomagnesemia?

10 : A client presents to the emergency department experiencing an acute asthma exacerbation. What assessment finding(s) should the nurse expect? Select all that apply.

1 :
A nurse received handoff report on four clients. Which client should the nurse recognize as being at risk for metabolic acidosis?

2 :
A nurse is attending to a client.

3 :
The nurse assesses a client admitted with stage 4 lung cancer reporting difficulty breathing. What additional finding should the nurse identify as most concerning?

4 :
A nurse is attending to a client with suspected bacterial pneumonia.

5 :
The nurse provides prescribed treatments for a client with fluid volume excess related to heart failure. What finding indicates to the nurse that the client's condition is worsening?

6 :
A nurse is attending to a client.

7 :
A nurse is attending to a client.

8 :
The nurse admits a client with a non-healing wound and reviews their electronic health record. What finding in the client's chart should the nurse identify as contributing to delayed wound healing?

9 :
What client is at risk for hypomagnesemia?

10 :
A client presents to the emergency department experiencing an acute asthma exacerbation. What assessment finding(s) should the nurse expect? Select all that apply.