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Question 1 of 5.

A client with COPD is in respiratory failure. Which of the following results would be the most sensitive indicator that the client requires a mechanical ventilator?

A. PCO2 58

B. SaO2 90

C. PH 7.23

D. HCO3 30

Explanation: A pH of 7.23 indicates severe respiratory acidosis, suggesting inadequate ventilation and the need for mechanical ventilation. PCO2 58 (A) and HCO3 30 (D) are elevated but less critical, and SaO2 90 (B) is low but not definitive.

Question 2 of 5.

A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually:

A. Oral itching after eating bananas

B. Swelling of the eyes and mouth

C. Difficulty in breathing

D. Swelling and itching of the hands

Explanation: Latex allergy often first presents as localized skin reactions, such as swelling and itching of the hands, due to direct contact with latex products.

Question 3 of 5.

During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:

A. Libel

B. Slander

C. Malpractice

D. Negligence

Explanation: Libel involves written defamatory statements, such as unverified suspicions of drug use in notes accessible to others, potentially harming the client's reputation.

Question 4 of 5.

A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:

A. Decreased blood pressure and constricted pupils

B. Increased heart rate and increased respirations

C. Increased respirations and increased blood pressure

D. Anoxia and absence of the cough reflex

Explanation: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.

Question 5 of 5.

During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:

A. Assess the drainage bag.

B. Check for bladder distention.

C. Unclamp the tubing.

D. Irrigate the tubing.

Explanation: Unclamping the nephrostomy tube is the priority to restore urine flow and prevent complications like hydronephrosis or infection.

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