NCN1530 Adult Health Nursing Exam - North Palm College of Nursing

Explanation:

Correct Answer: (A) Apply oxygen by mask or nasal cannula.

The ABG values reveal a critically low pH of 6.88, indicating severe acidosis, an elevated PaCO2 of 60 mm Hg reflecting CO2 retention and respiratory acidosis, and a dangerously low PaO2 of 50 mm Hg indicating hypoxemia. Following a prolonged tonic-clonic seizure, the muscles of respiration are fatigued and ventilation is compromised. The immediate life-threatening priority is hypoxemia, and applying supplemental oxygen is the first and most urgent intervention to correct oxygenation.

Why Other Options are Incorrect:

B. Apply a paper bag over the client's nose and mouth — This intervention is used for hyperventilation-induced respiratory alkalosis to increase CO2 rebreathing. In this case the patient already has CO2 retention and hypoxemia, making this intervention dangerous and contraindicated.

C. Administer 50 mL of sodium bicarbonate intravenously — Sodium bicarbonate may be considered in severe metabolic acidosis, but the primary problem here is respiratory acidosis from hypoventilation and hypoxemia. Correcting the breathing and oxygenation first is the appropriate priority.

D. Administer 50 mL of 20% glucose and 20 units of regular insulin — This intervention is used to treat hyperkalemia, not post-seizure respiratory acidosis or hypoxemia. It is not indicated in this clinical scenario.

Explanation:

Correct Answer: (C) Positive blood cultures

In a patient presenting with fever, chills, and leukocytosis, the clinical picture strongly suggests a systemic infectious process or bacteremia. Positive blood cultures confirm the presence of a pathogen in the bloodstream and are the expected and most diagnostically relevant laboratory finding in this scenario.

Why Other Options are Incorrect:

A. Elevated blood urea nitrogen (BUN) — Elevated BUN is associated with renal dysfunction or dehydration and is not a primary expected finding specific to an infectious process presenting with these symptoms.

B. Decreased white blood cell count — The patient already has leukocytosis, meaning the WBC is elevated. A decreased WBC would contradict the clinical data provided.

D. Normal platelet count — In a significant infectious or septic process, platelets may actually decrease due to consumption. A normal platelet count would not be the most expected finding in this clinical context.

Explanation:

Correct Answers: (A) Administer anticoagulants as prescribed, (C) Assess oxygen saturation levels frequently, and (E) Monitor for signs of respiratory distress

Anticoagulation is the cornerstone of pulmonary embolism treatment, preventing clot extension and new thrombus formation. Frequent oxygen saturation monitoring detects hypoxemia early, as PE impairs gas exchange by blocking pulmonary blood flow. Continuous monitoring for respiratory distress allows for rapid escalation if the patient deteriorates.

Why Other Options are Incorrect:

B. Position the patient in a supine position — Patients with PE and respiratory compromise should be placed in a semi-Fowler's or High-Fowler's position to optimize breathing. The supine position restricts diaphragmatic movement and worsens hypoxemia.

D. Encourage the patient to remain active — Activity is contraindicated in acute PE. Mobilization can dislodge the clot further or worsen hemodynamic instability. Rest is required during the acute phase of management.

Explanation:

Correct Answer: (B) Tachycardia and hypotension

Septic shock is characterized by the body's dysregulated response to infection leading to circulatory failure. Tachycardia occurs as a compensatory mechanism to maintain cardiac output, while hypotension reflects the severe vasodilation and vascular leak caused by systemic inflammation and mediator release.

Why Other Options are Incorrect:

A. Bradycardia and hypotension — Bradycardia is not a hallmark of septic shock; the cardiovascular response in sepsis is increased heart rate, not decreased.

C. Fever and hypoglycemia — While fever is common in sepsis, hypoglycemia alone does not define septic shock. Hyperglycemia is actually more commonly associated with the stress response in sepsis.

D. Leukopenia and hypertension — Hypertension is inconsistent with septic shock, which involves profound vasodilation and low blood pressure. Leukopenia can occur but is not the defining indicator of shock.

Explanation:

Correct Answer: (C) Natural active

Natural active immunity develops when a person is directly exposed to a pathogen and mounts their own immune response, producing memory B and T cells. These memory cells persist for decades and in many cases for life, providing the longest-lasting form of immunity. Because the immune system generates its own antibodies and cellular memory through actual infection, the resulting protection is the most durable of all immunity types.

Why Other Options are Incorrect:

A. Artificial active — Artificial active immunity results from vaccination, which stimulates the immune system to produce antibodies without causing disease. While it produces memory cells and can be long-lasting, it may require booster doses and generally does not last as long as natural active immunity.

B. Inflammatory — Inflammatory responses are nonspecific innate immune reactions to tissue injury or infection. They do not produce immunological memory and therefore confer no lasting immunity.

D. Natural passive — Natural passive immunity involves the transfer of maternal antibodies to a fetus or newborn through the placenta or breast milk. These antibodies are temporary and wane within weeks to months as the infant's body does not produce them independently.

Explanation:

Correct Answers: (C) Assisting a patient with deep breathing exercises, (D) Measuring oxygen saturation using a pulse oximeter, and (E) Documenting the patient's vital signs

CNAs can safely assist patients with deep breathing exercises as a supportive task that does not require clinical assessment or judgment. Measuring oxygen saturation with a pulse oximeter is a routine data-collection task within CNA scope of practice. Documenting vital signs is a standard CNA responsibility once values have been obtained.

Why Other Options are Incorrect:

A. Monitoring the patient's respiratory rate and effort — While a CNA can count respirations, interpreting respiratory effort and identifying signs of distress requires clinical nursing judgment and falls within the RN's assessment scope.

B. Administering inhaled bronchodilator therapy — Medication administration, including inhaled bronchodilators, is outside the CNA scope of practice and must be performed by a licensed nurse or respiratory therapist.

Explanation:

Correct Answer: (B) Neurological status.

A serum sodium level of 130 mEq/L indicates hyponatremia, which is below the normal range of 135 to 145 mEq/L. Sodium is the primary extracellular cation responsible for maintaining osmolality, and when sodium levels fall, water shifts into brain cells causing cerebral edema. This makes neurological status the priority assessment, as hyponatremia can cause headache, confusion, lethargy, seizures, and if severe, coma and death. Monitoring for changes in level of consciousness, orientation, and neurological function is the most critical and time-sensitive assessment in this situation.

Why Other Options Are Incorrect:

A. Lung sounds are relevant in conditions such as fluid overload or heart failure where pulmonary edema may develop, but they are not the priority assessment specific to the neurological dangers posed by hyponatremia.

C. Skin turgor is assessed to evaluate hydration status and dehydration, which is more relevant to hypernatremia. While it provides useful contextual information, it does not address the most serious and immediate risk associated with low sodium levels.

D. Blood pressure monitoring is always important but is not the priority assessment specific to hyponatremia. Cardiovascular compromise is more directly associated with other electrolyte imbalances and does not carry the same immediate neurological risk as cerebral edema from low sodium.

Explanation:

Correct Answer: (A) Oxygen saturation levels.

In a patient with COPD presenting with increased shortness of breath and wheezing, monitoring oxygen saturation is the most critical assessment because it directly reflects the adequacy of gas exchange and oxygenation. COPD causes chronic airflow limitation and impaired ventilation, and an acute exacerbation can rapidly compromise oxygen delivery to vital organs. Furthermore, patients with COPD are at risk for hypoxic respiratory drive suppression if oxygen is administered in excessive amounts, making continuous monitoring and careful titration of oxygenation levels an immediate and essential clinical priority.

Why Other Options Are Incorrect:

B. Blood glucose levels are not the priority assessment in a patient presenting with acute respiratory symptoms. While stress hyperglycemia can occur in acutely ill patients, it does not address the immediate respiratory compromise that defines this clinical presentation.

C. Abdominal girth measurement is relevant in conditions such as ascites, bowel obstruction, or abdominal aortic aneurysm. It has no direct relevance to the acute respiratory assessment of a COPD exacerbation with shortness of breath and wheezing.

D. Urine output is an important indicator of renal perfusion and fluid balance but is not the most critical assessment in the acute management of a COPD exacerbation. Respiratory function and oxygenation take precedence over renal monitoring in this context.

Explanation:

Correct Answer: (A) Administer high-ceiling (loop) diuretics.

In fluid overload, the immediate clinical priority is to reduce excess fluid volume to prevent life-threatening complications such as pulmonary edema and heart failure exacerbation. Loop diuretics such as furosemide act rapidly on the ascending loop of Henle to promote sodium and water excretion, making their administration the most urgent and directly therapeutic intervention.

Why Other Options are Incorrect:

B. Assess the client's lung sounds every 2 hours — While lung sound assessment is important for monitoring fluid status, assessment alone does not treat the fluid overload. The priority action must be an intervention that addresses the problem directly.

C. Place a pressure-relieving overlay on the mattress — Edematous skin is at risk for breakdown, making skin protection important, but this is not the priority action when the patient has active fluid overload requiring treatment.

D. Weigh the client daily at the same time on the same scale — Daily weights are an essential monitoring tool for fluid balance, but weighing the client is an assessment measure, not a treatment. It does not take priority over administering the prescribed therapeutic intervention.