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Questions in this quiz (194)
1The RN is providing care for a pt diagnosed with dehydration and hypovolemic shock. Which of the following orders should the nurse question?
- AMeasure BP every 15 mins
- BPlace two 18 gauge IV lines
- CO2 at 3L via nasal cannula
- DD5W to run at 250mL/hour
2The doc has written all of the following as orders for a pt with a dx of excess fluid volume. The pt's morning assessment revealed bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority?
- Aweigh the pt every morning
- Bmaintain accurate I & Os
- Crestrict fluids to 1500mL / day
- Dadminister furosemide (Lasix) 40mg IV push
3The client's nursing dx is deficient fluid volume r/t excessive fluid loss. Which action r/t fluid management should be delegated to CNA?
- Aadministering IV fluids as prescribed by doc
- Bproviding straws and offering fluid b/w meals
- Cdeveloping a plan for added fluid intake over 24 hours
- Dteaching family members to assist the client w/ fluid intake
4You are reviewing the client's morning labs. Which of these results is of most concern to you?
- Aserum K 5.2
- Bserum Na 134
- Cserum Ca 10.6
- Dserum Mg 0.8
5A nurse is assigned to change a central line dressing. The agency policy is to clean the site with povidone-iodine and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol should precede povidone-iodine in a dressing change. In addition, an article in a nursing journal stated that a new product was a more effective antibacterial than alcohol and povidone-iodine. The nurse has a sample of the new product. How should the nurse proceed?
- AUse the new product sample when changing the dressing.
- BCleanse the site with alcohol first and then with povidone-iodine
- CCleanse the site with the new product first and then follow the agency’s protocol.
- DFollow the agency’s policy unless it is contradicted by a primary healthcare provider’s prescription
6The nurse is caring for a client with the following arterial blood gas (ABG) values: PO2 89 mm Hg, PCO2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing which condition?
- AFluid balance
- BOxygen depletion
- CAcid-base balance
- DMetabolic acidosis
7An arterial blood gas report indicates the client's pH is 7.25, PCO2 is 35 mm Hg, and HCO3 is 20 mEq/L. Which disturbance should the nurse identify based on these results?
- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
8A client with a malignant parotid tumor is treated aggressively with radiation therapy and surgery. Postsurgical arterial blood gas results are as follows: pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq (25 mmol/L). The nurse should take which action?
- AObtain a prescription and administer a diuretic.
- BInstruct the client to breathe into a rebreather bag at a slow rate.
- CAsk the client to cough forcefully and take deep breaths
- DObtain a prescription for sodium bicarbonate
9A client who experienced smoke inhalation has a negative chest x-ray and arterial blood gases that demonstrate PaO2 of 75 mm Hg, PaCO2 of 45 mm Hg, and pH of 7.35. Which intervention should the nurse anticipate will be prescribed by the healthcare provider?
- ADeep suctioning
- BBronchodilators
- CBreathing exercises
- DMechanical ventilation
10A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60. These blood gases require nursing attention because they indicate which condition?
- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
11Surgery is performed on a client. The postoperative arterial blood gas values are pH 7.32, PCO2 53 mm Hg, and HCO3 25 mEq/L (25 mmol/L). Which action should the nurse take?
- AObtain a prescription for a diuretic
- BHave the client breathe into a rebreather bag
- CEncourage the client to take deep, cleansing breaths.
- DRequest a prescription for the administration of sodium bicarbonate
12A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first?
- APrepare to intubate the client
- BIncrease the oxygen flow rate per facility protocol.
- CDecrease the tension of oxygen in the plasma
- DHave the arterial blood gases redone to verify accuracy
13The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco2 of 50 mm Hg, HCO3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support what diagnosis?
- AHypocapnia
- BHyperkalemia
- CMetabolic alkalosis
- DRespiratory acidosis
14After a gastrectomy, a client has a nasogastric tube to low continuous suction. The client begins to hyperventilate. How does the nurse anticipate that this breathing pattern will alter the client's arterial blood gases?
- AIncrease the PO2 level
- BDecrease the pH level
- CIncrease the HCO3 level
- DDecrease the PCO2 level
15The client’s serum sodium is 123 mEq/L (123 mmol/L). Which prescription should the nurse question?
- AProvide pretzels as a snack daily
- BRestrict fluid intake to 1000 mL per day
- CAssess neurologic status every 2 hours
- DAdminister intravenous fluid of one-half normal saline (NS) at 125 mL/hr.
16A nurse administers an intravenous solution of 0.45% sodium chloride. In what category of fluids does this solution belong?
- AIsotonic
- BIsomeric
- CHypotonic
- DHypertonic
17The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?
- ACrohn disease
- BCushing disease
- CEnd-stage renal disease
- DGastroesophageal reflux disease
18What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply.
- ATetany
- BSeizures
- CDiarrhea
- DWeakness
- EDysrhythmias
19A nurse on the Code Blue/Arrest team responds to a code that is called for a client with hyperkalemia who is experiencing cardiac standstill. What would an appropriate immediate treatment plan include?
- ADefibrillation
- BFurosemide
- CSodium bicarbonate
- DAnticoagulation therapy
20A registered nurse teaches a student nurse regarding the management of increased potassium levels in a client. Which action performed by the student nurse indicates effective learning?
- AAdministering sodium polystyrene sulfonate
- BAvoiding potassium restriction
- CMonitoring glucose levels hourly
- DProviding potassium-sparing diuretics
21A client with a diagnosis of uncontrolled diabetes began receiving furosemide 2 days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L (Canada: 2.8 mmol/L). What is the most appropriate action for the nurse to take?
- AHold the morning dose of the diuretic and have the lab repeat the test.
- BContinue to monitor the level to ensure that it stays within the normal limits
- CNotify the primary healthcare provider of the critically low result
- DAnticipate a prescription for an increase in the dosage of the furosemide
22A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing?
- AHypernatremia
- BHyponatremia
- CHyperkalemia
- DHypokalemia
23A client's serum potassium level has increased to 5.8 mEq/L (5.8 mmol/L). What action should the nurse implement first?
- ACall the laboratory to repeat the test.
- BTake vital signs and notify the healthcare provider
- CInform the cardiac arrest team to place them on alert
- DTake an electrocardiogram and have lidocaine available
24A nurse is caring for a postoperative client who has a nasogastric (NG) tube set to low intermittent suction. The nurse recalls that the primary reason that an intravenous infusion of 5% dextrose with 0.45% sodium chloride and 20 mEq of potassium has been prescribed is to prevent which complication?
- AConstipation
- BDehydration
- CElectrolyte imbalance
- DNausea and vomiting
25A nurse administers a parenteral preparation of potassium slowly and cautiously to avoid which complication?
- AAcidosis
- BCardiac arrest
- CPsychoticlike reactions
- DEdema of the extremities
26Which client should a nurse consider the greatest risk for developing hypernatremia?
- AA 52-year-old who is receiving 0.45% NaCl intravenously
- BA 76-year-old who developed the syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a result of head trauma
- CA 63-year-old who has had watery diarrhea since traveling abroad
- DA 48-year-old who is admitted with a diagnosis of Addison disease
27A nurse assesses for hypocalcemia in a postoperative client. What is one of the initial signs that might be present?
- AHeadache
- BPallor
- CParesthesias
- DBlurred vision
28Which electrolyte concentration has the potential to precipitate dysrhythmias and cardiac arrest in a client?
- ASerum sodium of 139 mEq/L (139 mmol/L)
- BSerum chloride of 100 mEq/L (100 mmol/L)
- CSerum calcium of 10.2 mg/dL (2.55 mmol/L)
- DSerum potassium of 7.2 mEq/L (7.2 mmol/L)
29An older client comes to the emergency department after three days of diarrhea and is admitted to the hospital for rehydration therapy. In addition to sodium, what electrolyte should the nurse be concerned about most when the client's laboratory results are documented?
- ACa
- BChlorides
- CK
- DPhosphates
30A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results?
- ASodium and chloride levels
- BBicarbonate and sulfate levels
- CMagnesium and protein levels
- DCalcium and phosphate levels
31A client is admitted with severe diarrhea that resulted in hypokalemia. The nurse should monitor for what clinical manifestations of the electrolyte deficiency? Select all that apply.
- ADiplopia
- BSkin rash
- CLeg cramps
- DTachycardia
- EMuscle weakness
32A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?
- ASkin turgor
- BI & O results
- CClient's report about fluid intake
- DBlood lab results
33A client is hospitalized with dehydration. Which tasks are appropriate to delegate to a licensed practical nurse? Select all that apply.
- AFeeding
- BRecording the vital signs
- CAdministering oral fluids
- DHelping the client undress
- EPerforming oral-rehydration therapy
34A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates that which intravenous (IV) solution will be prescribed initially?
- A3% sodium chloride
- B0.9% sodium chloride
- C5% dextrose and 0.9% sodium chloride
- D5% dextrose and lactated Ringer solution
35A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/hour. One hour later, the client begins screaming, "I can't breathe!" How should the nurse respond?
- ADiscontinue the IV and notify the healthcare provider
- BElevate the head of the client's bed and obtain vital signs
- CAssess the client for allergies and change the IV to an intermittent lock
- DContact the healthcare provider to request a prescription for a sedative
36A client is diagnosed with acute kidney failure secondary to dehydration. An intravenous (IV) infusion of 50% glucose with regular insulin is prescribed. What does the nurse recognize as the primary purpose of the IV insulin for this client?
- ACorrect hyperkalemia
- BIncrease urinary output
- CPrevent respiratory acidosis
- DIncrease serum calcium levels
37The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. What type of respirations does the nurse expect the client to exhibit?
- ADyspnea
- BHyperpnea
- CKussmaul breathing
- DCheyne-Stokes breathing
38A client is admitted with dehydration. Which findings should the nurse expect the client to exhibit? Select all that apply.
- ASupple skin turgor
- BRapid, thready pulse
- CDecreased hematocrit
- DElevated specific gravity
- EAdventitious breath sounds
39A client presents with gastric pain, vomiting, dehydration, weakness, lethargy, and shallow respirations. Laboratory results indicate metabolic alkalosis. The diagnosis of gastric ulcer has been made. What is the primary nursing concern?
- AChronic pain
- BRisk for injury
- CElectrolyte imbalance
- DInadequate gas exchange
40A nurse reviews a list of medications that have been prescribed for a client. The nurse is aware that it is unsafe to administer which medication as an intravenous (IV) bolus?
- ASaline flush
- BPotassium chloride
- CNaloxone
- DAdenosine
41When receiving hemodialysis, the client may develop hyponatremia. For which clinical findings associated with hyponatremia should the nurse assess the client? Select all that apply.
- ADiarrhea
- BSeizures
- CChvostek sign
- DCardiac dysrhythmias
- EIncreased temperature
42A client is prone to hyponatremia. Which factors should the nurse identify that can precipitate hyponatremia? Select all that apply.
- AWound drainage
- BDiuretic therapy
- CGI suction
- DParenteral infusion of 0.9% sodium chloride
- EInadequate antidiuretic hormone (ADH) secretion
43A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings?
- ADigoxin (Lanoxin)
- BFurosemide (Lasix)
- CPropranolol (Inderal)
- DSpironolactone (Aldactone)
44A client begins to have difficulty breathing 30 minutes after the insertion of a subclavian central line. What should a nurse do first?
- ARaise HOB
- BApply O2
- CAssess breath sounds
- DCall the primary healthcare provider requesting a STAT chest x-ray.
45A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte?
- ANa
- BCa
- CK
- DPhosphorus
46A client is experiencing both tingling of the extremities and tetany. What should the nurse anticipate will be prescribed by the healthcare provider?
- ADialysis
- BCalcium supplements
- CMechanical ventilation
- DIntravenous fluids with potassium
47During the postoperative care of a 76-year-old patient, the nurse monitors the patient's intake and output carefully, knowing that the patient is at risk for fluid and electrolyte imbalances primarily because
- Aolder adults have an impaired thirst mechanism and need reminding to drink fluids.
- Bwater accounts for a greater percentage of body weight in the older adult than in younger adults.
- Colder adults are more likely than younger adults to lose extracellular fluid during surgical procedures.
- Dsmall losses of fluid are more significant because body fluids account for only about 50% of body weight in older adults.
48During administration of a hypertonic IV solution, the mechanism involved in equalizing the fluid concentration between ECF and the cells is
- Aosmosis
- Bdiffusion
- Cactive transport
- Dfacilitated diffusion
49An older woman was admitted to the medical unit with dehydration. Clinical indications of this problem are (select all that apply)
- Aweight loss
- Bdry oral mucosa
- Cfull bounding pulse
- Dengorged neck veins
- Edecreased central venous pressure
50The nursing care for a patient with hyponatremia includes
- Afluid restriction
- Badministration of hypotonic IV fluids
- Cadministration of a cation-exchange resin
- Dincreased water intake for patients on nasogastric suction
51The nurse should be alert for which manifestations in a patient receiving a loop diuretic?
- ARestlessness and agitation
- BParesthesias and irritability
- CWeak, irregular pulse and poor muscle tone
- DIncreased blood pressure and muscle spasms
52Which patient would be at greatest risk for the potential development of hypermagnesemia?
- A83-year-old man with lung cancer and hypertension
- B65-year-old woman with hypertension taking β-adrenergic blockers
- C42-year-old woman with systemic lupus erythematosus and renal failure
- D50-year-old man with benign prostatic hyperplasia and a urinary tract infection
53It is especially important for the nurse to assess for which clinical manifestation(s) in a patient who has just undergone a total thyroidectomy (select all that apply)?
- Aconfusion
- Bweight gain
- CDepressed reflexes
- DCircumoral numbness
- EPositive Chvostek's sign
54The nurse anticipates that treatment of the patient with hyperphosphatemia secondary to renal failure will include
- Afluid restriction
- Bcalcium supplements
- Cloop diuretic therapy.
- Dmagnesium supplements
55The lungs act as an acid-base buffer by
- Aincreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load
- Bincreasing respiratory rate and depth when CO2 levels in the blood are low, reducing base load.
- Cdecreasing respiratory rate and depth when CO2 levels in the blood are high, reducing acid load
- Ddecreasing respiratory rate and depth when CO2 levels in the blood are low, increasing acid load
56A patient has the following arterial blood gas results: pH 7.52; PaCO2 30 mm Hg; HCO3− 24 mEq/L. The nurse determines that these results indicate
- Ametabolic acidosis
- Bmetabolic alkalosis
- Crespiratory acidosis
- Drespiratory alkalosis
57The typical fluid replacement for the patient with a fluid volume deficit is
- Adextran
- B0.45% saline
- Clactated Ringer's
- D5% dextrose in 0.45% saline
58The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing intervention would be to
- Aapply warm moist compresses to the insertion site.
- Battempt to force 10 mL of normal saline into the device.
- Cplace the patient on the left side with head-down position.
- Dinstruct the patient to change positions, raise arm, and cough.
59A patient with consistent dietary intake who loses 1 kg of weight in 1 day has lost 1,000 mL of fluid.
- ATrue
- BFalse
60A man who weighs 90 kg has a total body water content of approximately 60L
- ATrue
- BFalse
61Adenosine triphosphate (ATP) is required for:
- AActive transport
- BOncotic pressure
- COsmotic pressure
- DFacilitated diffusion
62_____ uses a carrier molecule
- AFacilitated diffusion
- BHydrostatic pressure
- COsmosis
- DDiffusion
63Force exerted by a fluid
- AHydrostatic pressure
- BOsmosis
- CDiffusion
- DActive transport
64Pressure exerted by proteins
- AOncotic pressure
- BOsmotic pressure
- CFacilitated diffusion
- DHydrostatic pressure
65Force determined by osmolality of a fluid
- AOsmotic pressure
- BFacilitated diffusion
- CHydrostatic pressure
- DOsmosis
66Flow of water from low-solute concentration to high-solute concentration
- AOsmosis
- BDiffusion
- CActive transport
- DOncotic pressure
67Passive movement of molecules from a high concentration to lower concentration
- ADiffusion
- BActive transport
- COncotic pressure
- DOsmotic pressure
68As fluid circulates through the capillaries, there is movement of fluid between the capillaries and the interstitium. What describes the fluid movement that would cause edema (select all that apply)?
- APlasma hydrostatic pressure is less than plasma oncotic pressure.
- BPlasma oncotic pressure is higher than interstitial oncotic pressure.
- CPlasma hydrostatic pressure is higher than plasma oncotic pressure
- DPlasma hydrostatic pressure is less than interstitial hydrostatic pressure.
- EInterstitial hydrostatic pressure is lower than plasma hydrostatic pressure.
69What stimulates aldosterone secretion from the adrenal cortex?
- AExcessive water intake
- BIncreased serum osmolality
- CDecreased serum potassium
- DDecreased sodium and water
70While caring for an 84-year-old patient, the nurse monitors the patient’s fluid and electrolyte balance, recognizing what as a normal change of aging?
- AHyperkalemia
- BHyponatremia
- CDecreased insensible fluid loss
- DIncreased plasma oncotic pressures
71The nurse is admitting a patient to the clinical unit from surgery. Being alert to potential fluid volume alterations, what assessment data will be important for the nurse to monitor to identify early changes in the patient’s postoperative fluid volume (select all that apply)?
- AI & O
- BSkin turgor
- CLung sounds
- DRespiratory rate
- ELOC
72Which patient is at risk for hypernatremia?
- AHas a deficiency of aldosterone
- BHas prolonged vomiting and diarrhea
- CReceives excessive IV 5% dextrose solution
- DHas impaired consciousness and decreased thirst sensitivity
73In a patient with sodium imbalances, the primary clinical manifestations are related to alterations in what body system?
- AKidneys
- BCV system
- CMusculoskeletal system
- DCNS
74Alcohol withdrawal causes
- AHypophosphatemia
- BHypermagnesemia
- CHypomagnesemia
- DHypernatremia
75Metabolic alkalosis causes
- AHypokalemia
- BHypercalcemia
- CHypocalcemia
- DHyperphosphatemia
76Parathyroidectomy causes
- AHypocalcemia
- BHyperphosphatemia
- CHypophosphatemia
- DHypermagnesemia
77Diabetes insipidus causes
- AHypernatremia
- BHyponatremia
- CHyperkalemia
- DHypokalemia
78Fleet enemas cause
- AHyperphosphatemia
- BHypophosphatemia
- CHypermagnesemia
- DHypomagnesemia
79Primary polydipsia causes
- AHyponatremia
- BHyperkalemia
- CHypokalemia
- DHypercalcemia
80Milk of magnesia use in renal failure causes
- AHypermagnesemia
- BHypomagnesemia
- CHypernatremia
- DHyponatremia
81Early burn stage causes
- AHyperkalemia
- BHypokalemia
- CHypercalcemia
- DHypocalcemia
82Chronic alcoholism causes (select all)
- AHypocalcemia
- BHypomagnesemia
- CHyponatremia
- DHypernatremia
83Vitamin D deficiency causes
- AHypocalcemia
- BHyperphosphatemia
- CHypophosphatemia
- DHypermagnesemia
84Prolonged immobilization causes
- AHypercalcemia
- BHypocalcemia
- CHyperphosphatemia
- DHypophosphatemia
85Chronic kidney disease causes (select all)
- AHyperkalemia
- BHypocalcemia
- CHypophosphatemia
- DHypermagnesemia
86Loop and thiazide diuretics cause (select all)
- AHypokalemia
- BHyponatremia
- CHypocalcemia
- DHypomagnesemia
87A patient is taking diuretic drugs that cause sodium loss from the kidney. Which fluid or electrolyte imbalance is most likely to occur in this patient?
- AHyperkalemia
- BHyponatremia
- CHypocalcemia
- DHypotonic fluid loss
88A common collaborative problem related to both hyperkalemia and hypokalemia is which potential complication?
- Aseizures
- Bparalysis
- CDysrhythmias
- Dacute kidney injury
89What is hyperkalemia frequently associated with?
- AHypoglycemia
- BMetabolic acidosis
- CRespiratory alkalosis
- DDecreased urine potassium levels
90 In a patient with a positive Chvostek’s sign, the nurse would anticipate the IV administration of which medication?
- ACalcitonin
- BVitamin D
- CLoop diuretics
- DCalcium gluconate
91 A patient with chronic kidney disease has hyperphosphatemia. What is a commonly associated electrolyte imbalance?
- AHypokalemia
- BHyponatremia
- CHypocalcemia
- DHypomagnesemia
92What is the normal pH range of the blood and what ratio of base to acid does this reflect?
- A7.32 to 7.42; 25 to 2
- B7.32 to 7.42; 28 to 2
- C7.35 to 7.45; 20 to 1
- D7.35 to 7.45; 30 to 1
93What are characteristics of the phosphate buffer system (select all that apply)?
- ANeutralizes a strong base to a weak base and water
- BResultant sodium biphosphate is eliminated by kidneys
- CFree acid radicals dissociate into H+ and CO , buffering excess base
- DNeutralizes a strong acid to yield sodium biphosphate, a weak acid, and salt
- EShifts chloride in and out of red blood cells in exchange for sodium bicarbonate, buffering both acids and bases
94A patient who has a large amount of carbon dioxide in the blood also has what in the blood?
- ALarge amount of carbonic acid and low hydrogen ion concentration
- BSmall amount of carbonic acid and low hydrogen ion concentration
- CLarge amount of carbonic acid and high hydrogen ion concentration
- DSmall amount of carbonic acid and high hydrogen ion concentration
95Increased carbonic acid (H2CO3)
- ARespiratory acidosis
- BRespiratory alkalosis
- CMetabolic acidosis
- DMetabolic alkalosis
96 Increased base bicarbonate (HCO –)
- AMetabolic alkalosis
- BRespiratory acidosis
- CRespiratory alkalosis
- DMetabolic acidosis
97Decreased base bicarbonate (HCO –)
- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
98 What is a compensatory mechanism for metabolic alkalosis?
- AShifting of bicarbonate into cells in exchange for chloride
- BKidney conservation of bicarbonate and excretion of hydrogen ions
- CDeep, rapid respirations (Kussmaul respirations) to increase CO2 excretion
- DDecreased respiratory rate and depth to retain CO2 and kidney excretion of bicarbonate
99Renal failure causes
- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
100Severe shock causes
- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
101 Diabetic ketosis causes
- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
102Respiratory failure causes
- ARespiratory acidosis
- BRespiratory alkalosis
- CMetabolic acidosis
- DMetabolic alkalosis
103Prolonged vomiting causes
- AMetabolic alkalosis
- BRespiratory acidosis
- CRespiratory alkalosis
- DMetabolic acidosis
104Baking soda used as antacid causes
- AMetabolic alkalosis
- BRespiratory acidosis
- CRespiratory alkalosis
- DMetabolic acidosis
105Mechanical overventilation causes
- ARespiratory alkalosis
- BRespiratory acidosis
- CMetabolic acidosis
- DMetabolic alkalosis
106Sedative or opioid overdose causes
- ARespiratory acidosis
- BRespiratory alkalosis
- CMetabolic acidosis
- DMetabolic alkalosis
107 Response to anxiety, fear, and pain causes
- ARespiratory alkalosis
- BRespiratory acidosis
- CMetabolic acidosis
- DMetabolic alkalosis
108 To provide free water and intracellular fluid hydration for a patient with acute gastroenteritis who is NPO, the nurse would expect administration of which infusion?
- ADextrose 5% in water
- BDextrose 10% in water
- CLactated Ringer’s solution
- DDextrose 5% in normal saline (0.9%)
109What is an example of an IV solution that would be appropriate to treat an extracellular fluid volume deficit?
- AD5W
- B3% saline
- CLactated Ringer’s solution
- DD5W in 1⁄2 normal saline (0.45%)
110Priority Decision: On assessment of a central venous access device (CVAD) site, the nurse observes that the transparent dressing is loose along two sides. What should the nurse do immediately?
- AWait and change the dressing when it is due
- BTape the two loose sides down and document
- CApply a gauze dressing over the transparent dressing and tape securely.
- DRemove the dressing and apply a new transparent dressing using sterile technique
111A patient is scheduled to have a tunneled catheter placed for administration of chemotherapy for breast cancer. When preparing the patient for the catheter insertion, what does the nurse explain about this method of chemotherapy administration?
- ADecreases the risk for extravasation at the infusion site
- BReduces the incidence of systemic side effects of the drug
- CDoes not become occluded as peripherally inserted catheters can
- DAllows continuous infusion of the drug directly to the area of the tumor
112The nurse is reviewing a patient’s morning laboratory results. Which result is of greatest concern?
- ASerum Na+ of 150 mEq/L
- BSerum Mg2+ of 1.1 mEq/L
- CSerum PO 3– of 4.5 mg/dL
- DSerum Ca2+ (total) of 8.6 mg/dL
113The client’s nursing diagnosis is Deficient Fluid Volume related to excessive fluid loss. Which action related to fluid management should be delegated to a UAP?
- AAdministering IV fluids as prescribed by the physician
- BProviding straws and offering fluids between meals
- CDeveloping a plan for added fluid intake over 24 hours
- DTeaching family members to assist the client with fluid intake
114The client also has the nursing diagnosis Decreased Cardiac Output related to decreased plasma volume. Which assessment finding supports this nursing diagnosis?
- AFlattened neck veins when the client is in the supine position
- BFull and bounding pedal and post-tibial pulses
- CPitting edema located in the feet, ankles, and calves
- DShallow respirations with crackles on auscultation
115The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for an LPN/LVN being supervised by a nurse? (Select all that apply.)
- AReminding the client to avoid commercial mouthwashes
- BEncouraging mouth rinsing with warm saline
- CObserving the lips, tongue, and mucous membranes
- DProviding mouth care every 2 hours while the client is awake
- ESeeking a dietary consult to increase fluids on meal trays
116The health care provider has written all of these orders for a client with a diagnosis of Excess Fluid Volume. The client’s morning assessment reveals bounding peripheral pulses, weight gain of 2 lb, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
- AWeigh the client every morning
- BMaintain accurate intake and output records
- CRestrict fluids to 1500 mL/day.
- DAdminister furosemide (Lasix) 40 mg IV push.
117You have been floated to the telemetry unit for the day. The monitor watcher informs you that the client has developed prominent U waves. Which laboratory value should you check immediately?
- ANa
- BK
- CMg
- DCa
118A client’s potassium level is 6.7 mEq/L. Which intervention should you delegate to the first-year student nurse whom you are supervising?
- AAdminister sodium polystyrene sulfonate (Kayexalate) 15 g orally.
- BAdminister spironolactone (Aldactone) 25 mg orally
- CAssess the electrocardiogram (ECG) strip for tall T waves
- DAdminister potassium 10 mEq orally.
119A client is admitted to the unit with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). For which electrolyte abnormality would you be sure to monitor?
- AHypokalemia
- BHyperkalemia
- CHyponatremia
- DHypernatremia
120The charge nurse assigned the care of a client with acute kidney failure and hypernatremia to you, a newly-graduated RN. Which action can you delegate to the UAP?
- AProviding oral care every 3 to 4 hours
- BMonitoring for indications of dehydration
- CAdministering 0.45% saline by IV line
- DAssessing daily weights for trends
121An experienced LPN/LVN reports to you that a client’s blood pressure and heart rate have decreased, and when his face is assessed, one side twitches. What action should you take at this time?
- AReassess the client’s blood pressure and heart rate.
- BReview the client’s morning calcium level.
- CRequest a neurologic consult today.
- DCheck the client’s pupillary reaction to light.
122You are preparing to discharge a client whose calcium level was low but is now just barely within the normal range (9 to 10.5 mg/dL). Which statement by the client indicates to you the need for additional teaching?
- A“I will call my doctor if I experience muscle twitching or seizures.”
- B“I will make sure to take my vitamin D with my calcium each day.”
- C“I will take my calcium citrate pill every morning before breakfast.”
- D“I will avoid dairy products, broccoli, and spinach when I eat.”
123The UAP asks you why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response?
- A“The client’s low phosphorus is probably due to malnutrition.”
- B“The client is just worn out from not getting enough rest.”
- C“The client’s skeletal muscles are weak because of the low phosphorus.”
- D“The client will do more for himself when his phosphorus level is normal.”
124You are reviewing the client’s morning laboratory results. Which of these results is of most concern to you?
- ASerum potassium level of 5.2 mEq/L
- BSerum sodium level of 134 mEq/L
- CSerum calcium level of 10.6 mg/dL
- DSerum magnesium level of 0.8 mEq/L
125As the charge nurse, you would assign which client to the step-down unit nurse floated to the intensive care unit for the day?
- A68-year-old on a ventilator with acute respiratory failure and respiratory acidosis
- B72-year-old with chronic obstructive pulmonary disease (COPD) and normal blood gas values who is ventilator dependent
- CNewly-admitted 56-year-old with diabetic ketoacidosis receiving an insulin drip
- D38-year-old on a ventilator with narcotic overdose and respiratory alkalosis
126The client with respiratory failure is receiving mechanical ventilation and continues to produce arterial blood gas results indicating respiratory acidosis. Which change in ventilator setting should you expect to correct this problem?
- AIncrease in ventilator rate from 6 to 10 breaths/min
- BDecrease in ventilator rate from 10 to 6 breaths/min
- CIncrease in oxygen concentration from 30% to 40%
- DDecrease in oxygen concentration from 40% to 30%
127Which action should you delegate to a UAP for the client with diabetic ketoacidosis? (Select all that apply.)
- AChecking fingerstick glucose results every hour
- BRecording intake and output every hour
- CMeasuring vital signs every 15 minutes
- DAssessing for indicators of fluid imbalance
- ENotifying the provider of changes in glucose level
128You are admitting an older adult client to the medical unit. Which assessment factor alerts you that this client has a risk for acid-base imbalances?
- AHistory of myocardial infarction 1 year ago
- BAntacid use for occasional indigestion
- CShortness of breath with extreme exertion
- DChronic renal insufficiency
129A client with lung cancer has received oxycodone (Roxicodone) 10 mg orally for pain. When the student nurse assesses the client, which finding would you instruct the student to report immediately?
- ARespiratory rate of 8 to 10 breaths/min
- BDecrease in pain level from 6 to 2 (on a scale of 10)
- CRequest by the client that the room door be closed
- DHeart rate of 90 to 100 beats/min
130The UAP reports to you that a client seems very anxious, and vital sign measurement included a respiratory rate of 38 breaths/min. Which acid-base imbalance should you suspect?
- ARespiratory acidosis
- BRespiratory alkalosis
- CMetabolic acidosis
- DMetabolic alkalosis
131A client is admitted to your unit for chemotherapy. To prevent an acid-base problem, which finding would you instruct the UAP to report?
- ARepeated episodes of nausea and vomiting
- BReports of pain associated with exertion
- CFailure to eat all the food on the breakfast tray
- DClient hair loss during the morning bath
132The client has a nasogastric (NG) tube connected to intermittent wall suction. The student nurse asks why the client’s respiratory rate has decreased. What is your best response?
- A“It’s common for clients with uncomfortable equipment such as NG tubes to have a lower rate of breathing.”
- B“The client may have a metabolic alkalosis due to the NG suctioning, and the decreased respiratory rate is a compensatory mechanism.”
- C“Whenever a client develops a respiratory acid-base problem, decreasing the respiratory rate helps correct the problem.”
- D“The client is hypoventilating because of anxiety, and we will have to stay alert for the development of respiratory acidosis.”
133The client has an order for hydrochlorothiazide (HCTZ, Microzide) 10 mg orally every day. What should you be sure to include in a teaching plan for this drug? (Select all that apply.)
- A“Take this medication in the morning.”
- B“This medication should be taken in 2 divided doses when you get up and when you go to bed.”
- C“Eat foods with extra sodium every day.”
- D“Inform your prescriber if you notice weight gain or increased swelling.”
- E“You should expect your urine output to increase.”
134Which blood test result would you be sure to monitor for the client taking HCTZ?
- ANa level
- BK level
- CChloride level
- DCa level
135The RN is providing care for a patient diagnosed with dehydration and hypovolemic shock. Which order should the RN question?
- ABlood pressure every 15 minutes
- BPlace two 18-gauge IV lines
- COxygen at 3 L via nasal cannula
- DD5W to run at 250 mL/hr
136An experienced LPN/LVN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? (Select all that apply.)
- AAuscultating breath sounds
- BAdministering medications via metered-dose inhaler (MDI)
- CCompleting in-depth admission assessment
- DChecking oxygen saturation using pulse oximetry
- EDeveloping the nursing care plan
- FEvaluating the patient’s technique for using MDIs
137You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately?
- AFine bibasilar crackles
- BRespiratory rate of 8 breaths/min
- CThe patient sitting up and leaning over the nightstand
- DA large barrel chest
138The UAP tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem?
- AHumidify the patient’s oxygen
- BUse a simple face mask instead of a nasal cannula
- CProvide the patient with an extra pillow
- DHave the patient sit up in a chair at the bedside.
139You are supervising a student nurse who is performing tracheostomy care for a patient. Which action by the student would cause you to intervene?
- ASuctioning the tracheostomy tube before performing tracheostomy care
- BRemoving old dressings and cleaning off excess secretions
- CRemoving the inner cannula and cleaning using standard precautions
- DReplacing the inner cannula and cleaning the stoma site
140You are supervising an RN who floated from the medical-surgical unit to the emergency department. The nurse is providing care for a patient admitted with anterior epistaxis (nosebleed). Which directions would you clearly provide to the RN? (Select all that apply.)
- APosition the patient supine and turned on his side.
- BApply direct lateral pressure to the nose for 5 minutes
- CMaintain standard body substance precautions.
- DApply ice or cool compresses to the nose.
- EInstruct the patient not to blow the nose for several hours.
141A patient with sleep apnea has a nursing diagnosis of Sleep Deprivation related to disrupted sleep cycle. Which action should you delegate to the UAP?
- ADiscussing weight-loss strategies such as diet and exercise with the patient
- BTeaching the patient how to set up the bilevel positive airway pressure (BiPAP) machine before sleeping
- CReminding the patient to sleep on his side instead of his back
- DAdministering modafinil (Provigil) to promote daytime wakefulness
142You are acting as preceptor for a newly-graduated RN during her second week of orientation. You would assign the new RN under your supervision to provide nursing care to which patients? (Select all that apply.)
- A38-year-old with moderate persistent asthma awaiting discharge
- B63-year-old with a tracheostomy needing tracheostomy care every shift
- C56-year-old with lung cancer who has just undergone left lower lobectomy
- D49-year-old just admitted with a new diagnosis of esophageal cancer
- E76-year-old newly diagnosed with type 2 diabetes
143You are providing care for a patient with recently diagnosed asthma. Which key points would you be sure to include in your teaching plan for this patient? (Select all that apply.)
- AAvoid potential environmental asthma triggers such as smoke
- BUse the inhaler 30 minutes before exercising to prevent bronchospasm.
- CWash all bedding in cold water to reduce and destroy dust mites.
- DBe sure to get at least 8 hours of rest and sleep every night.
- EAvoid foods prepared with monosodium glutamate (MSG).
144A patient has chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to the UAP?
- AAssisting the patient to sit up on the side of the bed
- BInstructing the patient to cough effectively
- CTeaching the patient to use incentive spirometry
- DAuscultating breath sounds every 4 hours
145The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN/LVN under your supervision?
- AObserving how well the patient performs pursed-lip breathing
- BPlanning a nursing care regimen that gradually increases activity tolerance
- CAssisting the patient with basic activities of daily living (ADLs)
- DConsulting with the physical therapy department about reconditioning exercises
146The patient with COPD tells the UAP that he did not get his annual flu shot this year and has not had a pneumonia vaccination. You would be sure to instruct the UAP to report which vital sign value?
- ABlood pressure of 152/84 mm Hg
- BRespiratory rate of 27 breaths/min
- CHeart rate of 92 beats/min
- DOral temperature of 101.2° F (38.4° C)
147You are responsible for the care of a postoperative patient with a thoracotomy. The patient has been given the nursing diagnosis of Activity Intolerance. Which action should you delegate to the UAP?
- AInstructing the patient to alternate rest and activity periods
- BEncouraging, monitoring, and recording nutritional intake
- CMonitoring cardiorespiratory response to activity
- DPlanning activities for periods when the patient has the most energy
148You are supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. What finding would you clearly instruct the nursing student to notify you about immediately?
- AChest tube drainage of 10 to 15 mL/hr
- BContinuous bubbling in the water-seal chamber
- CReports of pain at the chest tube site
- DChest tube dressing dated yesterday
149After change of shift, you are assigned to care for the following patients. Which patient should you assess first?
- A68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory
- B57-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation
- C72-year-old with pneumonia who needs to be started on IV antibiotics
- D51-year-old with asthma who reports shortness of breath after using a bronchodilator inhaler
150You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to the UAP?
- ATeaching the patient about the importance of adequate fluid intake and hydration
- BAssisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed
- CReminding the patient to use an incentive spirometer every 1 to 2 hours while awake
- DEncouraging the patient to take a deep breath, hold it for 2 seconds, then cough two or three times in succession
151The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit?
- A58-year-old on airborne precautions for tuberculosis (TB)
- B65-year-old who just returned from bronchoscopy and biopsy
- C72-year-old who needs teaching about the use of incentive spirometry
- D69-year-old with COPD who is ventilator dependent
152When a patient with TB is being prepared for discharge, which statement by the patient indicates a need for further teaching?
- A“Everyone in my family needs to go and see the doctor for TB testing.”
- B“I will continue to take my isoniazid until I am feeling completely well.”
- C“I will cover my mouth and nose when I sneeze or cough and put my used tissues in a plastic bag.”
- D“I will change my diet to include more foods rich in iron, protein, and vitamin C.”
153You are admitting a patient for whom a diagnosis of pulmonary embolus must be ruled out. The patient’s history and assessment reveal all of these findings. Which finding supports the diagnosis of pulmonary embolus?
- AThe patient was recently in a motor vehicle crash.
- BThe patient participated in an aerobic exercise program for 6 months.
- CThe patient gave birth to her youngest child 1 year ago.
- DThe patient was on bed rest for 6 hours after a diagnostic procedure.
154Which intervention for a patient with a pulmonary embolus could be delegated to the LPN/LVN on your patient care team?
- AEvaluating the patient’s reports of chest pain
- BMonitoring laboratory values for changes in oxygenation
- CAssessing for symptoms of respiratory failure
- DAuscultating the lungs for crackles
155A patient with a pulmonary embolus is receiving anticoagulation with IV heparin. What instructions would you give the UAP who will help the patient with ADLs? (Select all that apply.)
- AUse a lift sheet when moving and positioning the patient in bed.
- BUse an electric razor when shaving the patient each day.
- CUse a soft-bristled toothbrush or tooth sponge for oral care.
- DUse a rectal thermometer to obtain a more accurate body temperature.
- EBe sure the patient’s footwear has a firm sole when the patient ambulates.
156A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action?
- APerform endotracheal intubation and initiate mechanical ventilation.
- BImmediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth.
- CAdminister furosemide (Lasix) 100 mg IV push immediately (STAT).
- DCall a code for respiratory arrest.
157You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately?
- AAssessing for bilateral breath sounds and symmetrical chest movement
- BAuscultating over the stomach to rule out esophageal intubation
- CMarking the tube 1 cm from where it touches the incisor tooth or nares
- DOrdering a chest radiograph to verify that tube placement is correct
158You are assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should you delegate to an experienced UAP?
- AAssessing the patient’s respiratory status every 4 hours
- BTaking vital signs and pulse oximetry readings every 4 hours
- CChecking the ventilator settings to make sure they are as prescribed
- DObserving whether the patient’s tube needs suctioning every 2 hours
159After the respiratory therapist performs suctioning on a patient who is intubated, the UAP measures vital signs for the patient. Which vital sign value should the UAP report to the RN immediately?
- AHeart rate of 98 beats/min
- BRespiratory rate of 24 breaths/min
- CBlood pressure of 168/90 mm Hg
- DTympanic temperature of 101.4° F (38.6° C)
160You are making a home visit to a 50-year-old patient who was recently hospitalized with a right leg deep vein thrombosis and a pulmonary embolism. The patient’s only medication is enoxaparin (Lovenox) subcutaneously. Which assessment information will you need to communicate to the physician?
- AThe patient says that her right leg aches all night.
- BThe right calf is warm to the touch and is larger than the left calf.
- CThe patient is unable to remember her husband’s first name.
- DThere are multiple ecchymotic areas on the patient’s arms.
161The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next?
- AReassure the patient that the ventilator will do the work of breathing for him.
- BManually ventilate the patient while assessing possible reasons for the high-pressure alarm.
- CIncrease the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning.
- DInsert an oral airway to prevent the patient from biting on the endotracheal tube.
162When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, you find that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate?
- AIncrease the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes.
- BAssist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs
- CAdminister the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation.
- DSwitch the patient to a nonrebreather mask at 95% to 100% FIO2 and call the physician to discuss the patient’s status.
163You have just finished assisting the physician with a thoracentesis for a patient with recurrent left pleural effusion caused by lung cancer. The thoracentesis removed 1800 mL of fluid. Which patient assessment information is important to report to the physician?
- AThe patient starts crying and says she can’t go on with treatment much longer.
- BThe patient reports sharp, stabbing chest pain with every deep breath.
- CThe blood pressure is 100/48 mm Hg and the heart rate is 102 beats/min.
- DThe dressing at the thoracentesis site has 1 cm of bloody drainage.
164You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care?
- AAdminister ordered antibiotics as scheduled.
- BHyperoxygenate the patient before suctioning.
- CMaintain the head of bed at a 30- to 45-degree angle.
- DSuction the airway when coarse crackles are audible.
165A patient with sleep apnea would like to avoid using a nasal CPAP device if possible. To help him reach this goal, the nurse suggests that the patient
- Alose excess weight.
- Btake a nap during the day
- Ceat a high-protein snack at bedtime.
- Duse mild sedatives or alcohol at bedtime.
166The physician has ordered continuous positive airway pressure (CPAP) for a patient with serious obstructive sleep apnea. How will CPAP help the patient?
- APrevent airway occlusion by bringing the tongue forward
- BBe easily tolerated by both the patient and the patient’s bed partner
- CProvide enough positive pressure in the airway to prevent airway collapse
- DDeliver a high inspiratory pressure and a low expiratory pressure to prevent airway collapse
167While caring for a patient following an uvulopalatopharyngoplasty (UPPP), the nurse monitors the patient for which complications in the immediate postoperative period?
- ASnoring and foul-smelling breath
- BInfection and electrolyte imbalance
- CLoss of voice and severe sore throat
- DAirway obstruction and hemorrhage
168Identify the acid-base imbalances represented by the following laboratory values:
pH 7.50
PaCO2 30 mm Hg
HCO3 24 mEq/L- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
169Identify the acid-base imbalances represented by the following laboratory values.
pH 7.62
PaCO2 48 mm Hg
HCO3 45 mEq/L- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
170 Identify the acid-base imbalances represented by the following laboratory values.
pH 7.20
PaCO2 25 mm Hg
HCO3 15 mEq/L- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
171 Identify the acid-base imbalances represented by the following laboratory values.
pH 7.26
PaCO2 56 mm Hg
HCO3 24 mEq/L- AMetabolic acidosis
- BMetabolic alkalosis
- CRespiratory acidosis
- DRespiratory alkalosis
172To promote the release of surfactant, the nurse encourages the patient to
- Atake deep breaths
- Bcough five times per hour to prevent alveolar collapse
- Cdecrease fluid intake to reduce fluid accumulation in the alveoli.
- Dsit with head of bed elevated to promote air movement through the pores of Kohn.
173A patient with a respiratory condition asks “How does air get into my lungs?” The nurse bases her answer on her knowledge that air moves into the lungs because of
- Acontraction of the accessory abdominal muscles.
- Bincreased carbon dioxide and decreased oxygen in the blood.
- Cstimulation of the respiratory muscles by the chemoreceptors.
- Ddecrease in intrathoracic pressure relative to pressure at the airway.
174The nurse can best determine adequate arterial oxygenation of the blood by assessing
- Aheart rate
- Bhemoglobin level.
- Carterial oxygen tension
- Darterial carbon dioxide tension
175A student nurse asks the RN what can be measured by arterial blood gases (ABGs). The RN tells the student that the ABGs can measure (select all that apply)
- Aacid-base balance.
- BO2 status
- Cacidity of the blood.
- Dglucose bound to hemoglobin
- Ebicarbonate (HCO3−) in arterial blood
176To detect early s/s of inadequate oxygenation the nurse would examine the pt for
- Adyspnea and hypotension
- Bapprehension and restlessness
- Ccyanosis and cool, clammy skin
- Dincreased urine output and diaphoresis
177During the respiratory assessment of an older adult, the nurse would expect to find (select all that apply)
- Aa vigorous cough.
- Bincreased chest expansion.
- Cincreased residual volume.
- Dincreased breath sounds in the lung apices.
- Eincreased anteroposterior (AP) chest diameter.
178When assessing activity-exercise patterns related to respiratory health, the nurse inquires about
- Adyspnea during rest or exercise
- Brecent weight loss or weight gain.
- Cability to sleep through the entire night.
- Dwillingness to wear oxygen equipment in public.
179When auscultating the chest of an older patient in respiratory distress, it is best to
- Abegin listening at the apices.
- Bbegin listening at the lung bases
- Cbegin listening on the anterior chest
- Dask the pt to breathe thru the nose w/ mouth closed
180Which assessment finding of the respiratory system does the nurse interpret as abnormal?
- AInspiratory chest expansion of 1 in
- BPercussion resonance over the lung bases
- CSymmetric chest expansion and contraction
- DBronchial breath sounds in the lower lung fields
181A patient’s arterial blood gas (ABG) results include the following: pH 7.32, PaO2 84 mm Hg, PaCO2 49 mm Hg, and SaO2 84%. For what should the nurse assess the patient?
- Atetany
- Btachypnea
- CPleural friction rub
- DKussmaul respirations
182The nurse would interpret an induration of 5mm resulting from a skin TB test as a positive finding in which pt?
- Aa pt w/ a Hx of illegal IV drug use
- Ba pt w/ DM and end-stage kidney disease
- Ca pt who immigrated from India 3 months ago
- Da pt who has HIV
183Asthma is a chronic disease of the airway
- ATrue
- BFalse
184Asthma is more common among females than males
- ATrue
- BFalse
185Asthma is curable
- ATrue
- BFalse
186asthma is generally Dx before adulthood
- ATrue
- BFalse
187The rate of asthma is _____ in children than adults.
- Ahigher
- Blower
- Cthe same
188A patient with a history of asthma is having shortness of breath. The nurse discovers that the peak flow meter indicates a peak expiratory flow (PEF) reading that is in the red zone. The nurse should immediately:
- ARepeat the PEF reading to verify the results
- BTake the patient’s vital signs
- CAdminister the rescue drugs
- DNotify the patient’s prescribe
189A pt has the following ABG results:
pH 7.48
PaO2 86
PaCO2 44
HCO3 29
When assessing th pt, the nurse would expect the pt to have:- Amuscle cramping
- Bwarm, flushed skin
- Crespiratory rate of 36
- DBP 94/52
190A 92-year-old female patient is being admitted to the emergency department with severe shortness of breath. Being aware of the patient’s condition, what approach should the nurse use to assess the patient’s lungs (select all that apply)?
- AApex to base
- BBase to apex
- CLateral sequence
- DAnterior then posterior
- EPosterior then anterior
191What keeps alveoli from collapsing?
- Acarina
- BSurfactant
- CEmpyema
- Dthoracic cage
192What accurately describes the alveolar sacs?
- ALine the lung pleura
- BWarm and moisturize inhaled air
- CTerminal structures of the respiratory tract
- DContain dead air that is not available for gas exchange
193What covers the larynx during swallowing?
- Atrachea
- BEpiglottis
- CTurbinates
- DParietal pleura
194A 75-year-old patient who is breathing room air has the following arterial blood gas (ABG) results: pH 7.40, PaO2 74 mm Hg, SaO2 92%, PaCO2 40 mm Hg. What is the most appropriate action by the nurse?
- ADocument the results in the patient’s record.
- BRepeat the ABGs within an hour to validate the findings.
- CEncourage deep breathing and coughing to open the alveoli.
- DInitiate pulse oximetry for continuous monitoring of the patient’s oxygen status.
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- Med/Surg 1 Quiz on 1st Exam, created by Nicole Buda on 06/01/2017.
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- Nicole Buda
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