Question

A patient hyperventilating from anxiety has a pH 7.50, PaCO₂ 28 mmHg. The nurse understands:

Answer 1

Correct Answers:

Excessive CO₂ loss causes respiratory alkalosis.

Rationale :

💁‍♂️Hyperventilation blows off too much carbon dioxide (CO₂) from the lungs.

📉Low PaCO₂ (28 mmHg) indicates excess CO₂ loss, not retention.

🧪High pH (7.50) shows the blood is becoming more alkaline.

👃Respiratory alkalosis occurs when ventilation increases and PaCO₂ drops.

📌Core Message

Hyperventilation lowers PaCO₂, producing respiratory alkalosis.

Answer 2

Correct Answers:

Aura

Rationale :

👃Aura is a sensory warning that can happen before a seizure starts.

⚡Strange smells are a classic olfactory aura reported by some clients.

🧠Aura represents focal onset symptoms that may progress to a generalized seizure.

💁‍♂️Prodromal changes are more general and hours/days before, unlike a sudden smell right before.

📌Core Message

A sudden strange smell before a seizure is an aura.

Answer 3

Correct Answers:

Massive proteinuria and generalized edema

Rationale :

🧫Nephrotic syndrome is defined by massive proteinuria due to increased glomerular permeability.

💧Loss of albumin lowers oncotic pressure, causing generalized edema.

🩸Glomerulonephritis more typically presents with hematuria and inflammatory findings.

💁‍♂️The most distinguishing feature for nephrotic syndrome is heavy protein loss with edema.

📌Core Message

Nephrotic syndrome is marked by massive proteinuria and generalized edema.

Answer 4

Correct Answers:

Protect the airway

Rationale :

🛡️During active seizure, the top priority is airway protection to prevent aspiration.

💁‍♂️Maintaining oxygenation and safe positioning supports breathing during convulsions.

🚫Placing an oral airway during a seizure risks injury and is unsafe.

👉Prioritizing airway follows ABCs and prevents life-threatening complications.

📌Core Message

For an actively seizing client, protect the airway using ABCs.

Answer 5

Correct Answers:

Overdose may occur since the accurate dosage of street drugs is unknown.

Rationale :

⚠️Street drugs often have unknown potency and may be mixed with dangerous additives.

📏Because dosing is unpredictable, users can unintentionally take a toxic amount.

💉Needle sharing increases infection risk, so saying infection is uncommon is incorrect.

💁‍♂️The clearest complication listed is overdose from unreliable dosing.

📌Core Message

Overdose risk is high because street drug potency is unpredictable.

Answer 6

Correct Answers:

Positive Trousseau's sign
Stridor
Positive Chvostek's sign

Rationale :

🦴Hypocalcemia increases neuromuscular excitability, leading to tetany signs.

✋Trousseau’s sign reflects carpopedal spasm triggered by ischemia from a BP cuff.

😊Chvostek’s sign reflects facial nerve irritability when the cheek is tapped.

💁‍♂️Stridor can occur from laryngospasm, a serious airway complication of hypocalcemia.

📌Core Message

Hypocalcemia causes tetany signs like Trousseau’s, Chvostek’s, and possible stridor.

Answer 7

Correct Answers:

Metabolic alkalosis

Rationale :

🧪NG suction removes gastric acid (H⁺) from the stomach.

📈Losing hydrogen ions shifts the body toward alkalinity.

🧂This often raises bicarbonate (HCO₃⁻) relative to acids, causing metabolic alkalosis.

👉Therefore, prolonged NG suctioning most commonly leads to metabolic alkalosis.

📌Core Message

NG suctioning removes H⁺, leading to metabolic alkalosis.

Answer 8

Correct Answers:

Holding abdomen
Bent forward
Grimacing

Rationale :

😖Grimacing is a classic nonverbal pain indicator.

🤕Guarding/holding the abdomen suggests localized discomfort and protective behavior.

🧍‍♂️Bent-forward posture can reduce abdominal pain by decreasing muscle stretch.

💁‍♂️These behaviors are more consistent with pain cues than neutral actions like simply sitting.

📌Core Message

Pain is often shown by grimacing, guarding, and protective posture.

Answer 9

Correct Answers:

PH-7.38, CO₂-42, HCO₃-24

Rationale :

🧪Normal pH is 7.35–7.45, and 7.38 fits this range.

🌬️Normal PaCO₂ is 35–45, and 42 is within normal.

🧂Normal HCO₃⁻ is 22–26, and 24 is normal.

💁‍♂️All three values are within expected ABG normal ranges, making option D correct.

📌Core Message

A normal ABG has normal pH, normal PaCO₂, and normal HCO₃⁻.

Answer 10

Correct Answers:

Respiratory Acidosis

Rationale :

💁‍♂️Pneumonia can impair alveolar ventilation by filling alveoli with exudate.

📉Reduced ventilation causes CO₂ retention, increasing PaCO₂.

🧪Rising PaCO₂ drives the blood toward acidosis, creating respiratory acidosis.

👉Therefore, significant pneumonia-related hypoventilation most aligns with respiratory acidosis.

📌Core Message

Severe pneumonia can cause CO₂ retention, leading to respiratory acidosis.

1 :
A patient hyperventilating from anxiety has a pH 7.50, PaCO₂ 28 mmHg. The nurse understands:

2 :
A client describes a "strange smell" before they experience a seizure. The client is describing what stage of a tonic-clonic seizure?

3 :
Which clinical finding is more characteristic of nephrotic syndrome compared to glomerulonephritis?

4 :
What is a priority for a client actively seizing?

5 :
Which describes a potential complication associated with substance abuse?

6 :
Which of the following clinical manifestations would a nurse associate with hypocalcemia? Select all that apply.

7 :
A nurse is evaluating a client with NG suctioning. What acid-base imbalance is most likely?

8 :
Which signs may show pain? (Select all)

9 :
Which is a normal arterial blood gas (ABG) result?

10 :
A client with pneumonia is most likely to experience which of the following acid-base imbalances?

1 : A patient hyperventilating from anxiety has a pH 7.50, PaCO₂ 28 mmHg. The nurse understands:

2 : A client describes a "strange smell" before they experience a seizure. The client is describing what stage of a tonic-clonic seizure?

3 : Which clinical finding is more characteristic of nephrotic syndrome compared to glomerulonephritis?

4 : What is a priority for a client actively seizing?

5 : Which describes a potential complication associated with substance abuse?

6 : Which of the following clinical manifestations would a nurse associate with hypocalcemia? Select all that apply.

7 : A nurse is evaluating a client with NG suctioning. What acid-base imbalance is most likely?

8 : Which signs may show pain? (Select all)

9 : Which is a normal arterial blood gas (ABG) result?

10 : A client with pneumonia is most likely to experience which of the following acid-base imbalances?

1 :
A patient hyperventilating from anxiety has a pH 7.50, PaCO₂ 28 mmHg. The nurse understands:

2 :
A client describes a "strange smell" before they experience a seizure. The client is describing what stage of a tonic-clonic seizure?

3 :
Which clinical finding is more characteristic of nephrotic syndrome compared to glomerulonephritis?

4 :
What is a priority for a client actively seizing?

5 :
Which describes a potential complication associated with substance abuse?

6 :
Which of the following clinical manifestations would a nurse associate with hypocalcemia? Select all that apply.

7 :
A nurse is evaluating a client with NG suctioning. What acid-base imbalance is most likely?

8 :
Which signs may show pain? (Select all)

9 :
Which is a normal arterial blood gas (ABG) result?

10 :
A client with pneumonia is most likely to experience which of the following acid-base imbalances?