Arterial blood gas levels are obtained for the client. If the client’s results are pH 7.48, CO2 42 mm Hg, and HCO3 32 mEq/L, the client is exhibiting
... [Show More] which one of the following acid-base imbalances?
Selected Answer: D.
Metabolic alkalosis
Correct Answer: D.
Metabolic alkalosis
Response Feedback:
The client’s pH is elevated at 7.48 (normal 7.35 to 7.45), the CO2 is normal at 42 mm Hg (normal 35 to 45 mm Hg), and the bicarbonate is elevated at 32 mEq/L (normal 22 to 26 mEq/L). The client is experiencing metabolic alkalosis. In metabolic acidosis the client’s pH would be below 7.35, and the bicarbonate would be below 22 mEq/L. In respiratory acidosis the client’s pH would be below 7.35, and the CO2 would be elevated above 45 mm Hg. In respiratory alkalosis the client’s pH would be above 7.45, and the CO2 would be below 35 mm Hg.Cognitive Level: analysisNCLEX Blueprint: Physiological Adaptation
• Question 2
The nurse would suspect that a client who frequently uses which medication is at risk for developing metabolic alkalosis?
Selected Answer: A.
Calcium carbonate (Tums)
Correct Answer: A.
Calcium carbonate (Tums)
Response Feedback:
Excessive use of oral antacids can lead to metabolic alkalosis. Use of ibuprofen and Tylenol is not associated with the development of metabolic alkalosis. Overdoses of aspirin can be associated with the development of respiratory alkalosis, and eventually can lead to metabolic acidosis.
Cognitive Level: ApplicationNCLEX Blueprint: Physiological Adaptation
• Question 3
The nurse records a patient’s hourly urine output from an indwelling catheter as follows:0700: 36 mL0800: 45 mL0900: 85 mL1000: 62 mL1100: 50 mL1200: 48 mL1300:
94 mL1400: 78 mL1500: 60 mLThe nurse can conclude that the patient’s urine output should be described as which of the following?
Selected Answer: B.
Within normal limits
Correct Answer: B.
Within normal limits
Response Feedback:
Urine accounts for the greatest amount of fluid loss. Normal urine output for an average-sized adult is approximately 1,500 mL in 24 hr. Urine output varies according to intake and activity but should remain at least 30 to 50 mL per hour. The patient’s urine output is within the normal range. This patient has an indwelling catheter, which will result in continual flow of urine.Cognitive level: analysisNCLEX Blueprint: basic care and comfort
• Question 4
A client is admitted with severe diarrhea. Arterial blood gas (ABG) results are pH 7.33; PaCO 2 42; HCO 3 – 20. The nurse concludes this client has which acid–base imbalance?
Selected Answer: A.
Uncompensated metabolic acidosis
Correct Answer: A.
Uncompensated metabolic acidosis
Response Feedback:
The pH and HCO3– are decreased, indicating metabolic acidosis. The PaCO2 is normal, indicating that compensatory mechanisms have not started working. Compensated or uncompensated respiratory acidosis is incorrect because the primary disturbance is metabolic, as indicated by the low bicarbonate level. Compensated metabolic acidosis is incorrect because with compensation, a decrease in PaCO2 to restore balance would be expected. Cognitive Level: AnalyzingNCLEX Blueprint: Physiological Adaptation
• Question 5
Identify the appropriate intervention(s) for a patient with hypovolemia. Choose all that apply.
B.
Monitor I&O daily.
C.
Encourage fluid intake.
D.
Monitor electrolyte balance.
Correct Answers: B.
Response Feedback:
Monitor I&O daily.
C.
Encourage fluid intake.
D.
Monitor electrolyte balance.
Hypovolemia occurs when more fluid is lost than is taken into the body. Monitoring I&O provides information to evaluate the status of the problem. Encouraging fluid intake helps to correct the problem. It is good to monitor electrolytes because electrolyte imbalance can occur with hypovolemia (although it may not occur at first). Deep-breathing techniques do not address fluid balance; there is no evidence that the patient has a respiratory disorder.Cognitive level: ApplicationNCLEX Blueprint: physiological adaptation
• Question 6
While caring for a patient preparing for a kidney transplant, the nurse knows that the patient understands teaching on immunosuppression when she states which of the following?
Selected Answer:
Correct Answer:
Response Feedback:
C.
"The medications that I take will help prevent my body from attacking my new kidney."
C.
"The medications that I take will help prevent my body from attacking my new kidney."
Immunosuppressant therapy is initiated to inhibit optimal immune response. This is necessary in the case of transplantation, because the normal immune response would cause the body to recognize the new tissue as foreign and attack it. The body will identify the new kidney as foreign and will not treat it as the original kidney. While patients with transplants must be careful about exposure to others, especially those who are or might be ill, and practice adequate and consistent infection control techniques, they don't have to avoid people or social interaction. The new kidney brings foreign cells regardless of relationship between donor and recipient.Cognitive Level: ApplicationNCLEX Blueprint: Health promotion and Maintenance
• Question 7
The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report most urgently to the physician?
Selected Answer: A.
Swollen ankles in patient with compensated heart failure
Correct Answer: B.
Positive Chvostek's sign in patient with acute pancreatitis
Response Feedback:
Positive Chvostek's sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening.
Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek's sign.Cognitive level: applicationNCLEX Blueprint: reduction of risk potential
• Question 8
The nurse is completing a physical assessment with a client. Which of the following findings could be caused by impaired immune function in the client?
Selected Answer: C.
Leg rash
Correct Answer: C. Leg rash
Response Feedback:
Of the assessment findings provided, leg rash could be caused by impaired immune function in the client. Jugular vein distention, neck pain, and hip pain would most likely have another cause.Cognitive Level: AnalysisNCLEX Blueprint: Physiological Adaptation
• Question 9
Which set of assessment data is consistent for a patient with severe infection that could lead to system failure?
Selected Answer:
Correct Answer:
B.
BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours
B.
BP 90/48, P 112 beats/min, RR 26 breaths/min, urine output 240 mL in past 24 hours
Response Feedback:
The patient with severe infection presents with low BP and compensating elevations in pulse to move lower volumes of blood more rapidly and respiration to increase access to oxygen. Urine output decreases to counteract the decreased circulating blood volume and hypotension. These vital signs are all too low: Blood pressure (BP) 92/52, pulse (P) 56 beats/min, respiratory rate (RR) 10 breaths/min, urine output 1200 mL in past 24 hours. The patient with severe infection does have a low BP, but the pulse and respiratory rate increase to compensate. This data is all within normal limits: BP 112/64, P 98 beats/min, RR 18 breaths/min, urine output 2400 mL in past 24 hours. This set of data reflects an elevated BP with a decrease in pulse and respiratory rates along with normal urine output: BP 152/90, P 52 beats/min, RR 12 breaths/min, urine output 4800 mL in past 24 hours. None of these is a typical response to severe infection.Cognitive level: applicationNCLEX Blueprint: physiological adaptation
• Question 10
A patient is receiving an IV infusion of lactated Ringer’s solution and 40 mEq of KCl at 100 mL/hr. When assessing the IV site, the nurse notes swelling, erythema, and warmth. There is a palpable cord along the vein, and the infusion is sluggish. The patient is complaining of pain at the site. The nurse would recognize these findings to be consistent with which of the following?
Selected Answer: D.
Phlebitis
Correct Answer: D. Phlebitis
Response Feedback:
Phlebitis is an inflammation of the vein. It may be caused by the infusion of solutions that are irritating to the vein. Patients receiving IV solutions with potassium chloride are at a higher risk for phlebitis, as it is irritating to the vein. The symptom of a palpable cord along the vein distinguishes this as phlebitis. Infiltration presents as erythema, pain, and swelling. However, there is no palpable cord with inflammation. Extravasation is infiltration of a vesicant substance into the tissues. Differentiating symptoms include blanching and coolness of the surrounding skin; the formation of blisters and subsequent tissue sloughing and necrosis are later signs. A hematoma is a localized mass of blood outside the blood vessel. This is generally seen when a vein is nicked during an unsuccessful insertion of an IV line or when an IV line is discontinued without pressure applied over the site.Cognitive level: analysisNCLEX Blueprint: basic care and comfort
• Question 11
The nurse is preparing to administer medications to a patient with rheumatoid arthritis (RA). The nurse explains to the patient that the goal of medication treatments for RA is to
Selected Answer: C.
control inflammation.
Correct Answer: C.
control inflammation.
Response Feedback:
Medications for RA are intended to control the inflammation that results from the body's hyperimmune response. Autoimmune diseases like RA are chronic and currently have no curative treatments. Autoimmune diseases like RA are caused by hyperimmune response. The immune system needs to be suppressed, not enhanced. While the medications used for RA might help with pain management, the goal of medication intervention is to manage the inflammation.Cognitive Level: ApplicationNCLEX Blueprint: Health promotion and Maintenance
• Question 12
The parents of a newborn question the nurse about the need for vaccinations: "Why does our baby need all those shots? He's so small, and they have to cause him pain." The nurse can explain to the parents that which of the following are true about vaccinations? (Select all that apply.)
Correct Answers:
Response Feedback:
B.
Prevent the child from getting childhood diseases
C.
Help protect individuals and communities
E.
Are recommended by the Centers for Disease Control and Prevention (CDC)
A.
Are part of primary prevention for system disorders
C.
Help protect individuals and communities
E.
Are recommended by the Centers for Disease Control and Prevention (CDC)
Rationale:Immunizations are considered part of primary prevention, help protect individuals from contracting specific diseases and from spreading them to the community at large, and are recommended by the CDC. Vaccination does not guarantee that the recipient won't get the disease, but it decreases the potential to contract the illness. No medication is risk
free.Cognitive Level: ComprehensionNCLEX Blueprint: Health Promotion and Maintenance
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