BSN 266 HESI SHERPARTH
QUIZZES EXAM QUESTIONS
AND ANSWERS
Question 8 of 12
The patient's ABG analysis is as follows: pH - 7.2; PaCO2 - 60 mm Hg; PaO2 - 73 mm
Hg; HCO3− - 25 mEq/L. The nurse identifies the nursing diagnostic statement of
Impaired Gas Exchange r/t COPD AEB ABG results. Which goal statement should the
nurse include in the plan of care?
Patient's pH value will return to a level between 7.35 and 7.45 within 12 hours.
Patient's oxygen saturation will be > 97% within 12 hours.
Patient will be able to walk 100 feet down the hall with a respiratory rate less than 22
breaths per minute by Day 3 of hospital stay.
The patient will require decreased supplemental oxygen based on assessment data. -
Answer-Patient's pH value will return to a level between 7.35 and 7.45 within 12 hours.
This goal is specific and realistic and is appropriate for the nurse to include in the plan
of care
Question 9 of 12
Which intervention should the nurse include in the plan of care for a patient who is
experiencing respiratory alkalosis?
Preparing for mechanical ventilation
Increasing fluid intake
Facilitating a cough
Breathing into a paper bag - Answer-Breathing into a paper bag
Breathing into a paper bag is an appropriate intervention for a patient who is
experiencing respiratory alkalosis.
Question 10 of 12
Which nursing action is appropriate when providing care to a patient who is
experiencing metabolic alkalosis?
Preparing for mechanical ventilation
Administering the ordered sodium bicarbonate
Initiating seizure precautions
Holding foods rich in potassium - Answer-Initiating seizure precautions
Patients who are experiencing metabolic alkalosis are at risk for seizure activity.
Therefore, this is an appropriate nursing action when providing care to a patient who is
experiencing metabolic alkalosis.
,Question 11 of 12
The nurse is planning a collaborative care conference for a patient diagnosed with an
acid-base imbalance. Which members of the healthcare team should the nurse include
during the acute phase of any acid-base imbalance?
Select all that apply.
Unlicensed assistive personnel (UAP)
Physical therapist (PT)
Primary care provider (PCP)
Respiratory therapist (RT)
Occupational therapist (OT) - Answer-Primary care provider (PCP)
The PCP is an essential member of the collaborative healthcare team who will be
involved in providing patient care during the acute phase of an acid-base imbalance.
Correct
Respiratory therapist (RT)
The RT is an essential member of the collaborative healthcare team who will be
involved with providing patient care during the acute phase of an acid-base imbalance.
Question 12 of 12
Which interventions should the nurse implement for a patient who is experiencing
respiratory acidosis?
Select all that apply.
Increase the rate of IV fluid administration
Encourage deep breathing exercises
Monitor breath sounds
Provide emotional support
Administer prescribed narcotic - Answer-Encourage deep breathing exercises
The nurse can independently encourage the patient to complete deep breathing
exercises.
Correct
Monitor breath sounds
The nurse should monitor the patient's breath sounds due to the current respiratory
status.
Correct
Provide emotional support
The nurse should provide emotional support for the patient who is experiencing an acid-
base imbalance.
Nursing Diagnosis and Planning Related to Electrolyte Imbalances:
Question 1 of 7
The nurse identifies hypokalemia in a patient. Which findings on the nursing
assessment may be associated with this electrolyte imbalance?
Select all that apply.
Bradycardia
Hypertension
Poor muscle tone
Poor skin turgor
,Increased blood glucose levels - Answer-Bradycardia
The heart rate is affected by hypokalemia. Bradycardia is an assessment finding that
may be related to hypokalemia.
Correct
Hypertension
The blood pressure is affected by hypokalemia. Hypertension is an assessment finding
that may be related to hypokalemia.
Correct
Poor muscle tone
The neuromuscular system is affected by hypokalemia. Poor muscle tone is an
assessment finding that may be related to hypokalemia.
Correct
Poor skin turgor
Nausea and vomiting occur with hypokalemia, which leads to dehydration. Poor skin
turgor is an assessment finding that may be related to hypokalemia.
Question 2 of 7
The nurse identifies the nursing diagnosis of Imbalanced nutrition: less than body
requirements related to anorexia, nausea, and vomiting. Which electrolyte imbalance
should the nurse use as the "as evidenced by" portion for this nursing diagnostic
statement?
Hypercalcemia
Hypernatremia
Hyperkalemia
Hypermagnesemia - Answer-Hypercalcemia
Hypercalcemia (high levels of calcium in the blood) is often the cause of anorexia,
nausea, and vomiting. Therefore, this is an appropriate term to use as the "as
evidenced by" portion of the nursing diagnostic statement.
Question 3 of 7
The nurse is providing care to a patient with electrolyte imbalance showing edema and
shortness of breath. Which nursing diagnosis should the nurse include in the updated
patient plan of care?
Imbalanced nutrition: less than body requirements r/t electrolyte imbalance, as
evidenced by shortness of breath
Acute confusion related to electrolyte imbalances, as evidenced by edema and
shortness of breath
Fluid volume excess related to electrolyte imbalances, as evidenced by edema and
shortness of breath
Altered cardiac output related to fluid in the lungs, as evidenced by edema and
shortness of breath - Answer-Fluid volume excess related to electrolyte imbalances, as
evidenced by edema and shortness of breath
This nursing diagnostic statement is accurate because the electrolyte imbalance is
causing the nursing diagnosis of Fluid volume excess, which is manifested by edema
and shortness of breath.
, Question 4 of 7
The nurse identifies the nursing diagnosis Risk for electrolyte imbalance for an older
adult patient experiencing nausea, vomiting, and diarrhea. Which is an accurate goal
statement for the nurse to include in the patient's plan of care?
Patient's serum potassium level will be within the normal range of 3.5-5.0 mEq/L during
the hospitalization.
Patient's serum sodium level will be within the normal range of 1.5-2.0 mEq/L during the
hospitalization.
Patient's serum calcium level will be within the normal range of 135-145 mEq/L during
the hospitalization.
Patient's serum magnesium level will be within the normal range of 8.4-10.2 mg/dL
during the hospitalization. - Answer-Patient's serum potassium level will be within the
normal range of 3.5-5.0 mEq/L during the hospitalization.
This is an accurate goal for the patient as the normal range for potassium is 3.5-5.0
mEq/L.
Question 5 of 7
The nurse is planning care for a patient whose nursing diagnosis is Decreased cardiac
output related to electrolyte imbalance. The NOC for this nursing diagnosis is Cardiac
pump effectiveness. Which indicators should the nurse monitor to determine the
effectiveness of the current plan of care?
Select all that apply.
Apical heart rate and rhythm
Blood pressure
Heart sounds
Serum potassium
Nutrient intake - Answer-Blood pressure
Blood pressure is an indicator used by the nurse to determine the effectiveness of the
plan of care to address the NOC of Cardiac pump effectiveness.
Correct
Heart sounds
Heart sounds is an indicator used by the nurse to determine the effectiveness of the
plan of care to address the NOC of Cardiac pump effectiveness.
Question 6 of 7
Which goal should the nurse include in the plan of care for a patient whose priority
nursing diagnosis is Acute pain related to electrolyte imbalances, as evidenced by
muscle cramping?
Patient's serum electrolyte levels will be normal within 48 hours of implementing
prescribed treatment.
Patient will report a muscle cramp pain rating of no more than 3 on a 1 to 10 numeric
scale within 1 hour of implementing prescribed treatment.
Patient will achieve Pain control during hospitalization.
Patient will consume adequate nourishment during hospitalization, including foods rich
in electrolytes. - Answer-Patient will report a muscle cramp pain rating of no more than
3 on a 1 to 10 numeric scale within 1 hour of implementing prescribed treatment.
QUIZZES EXAM QUESTIONS
AND ANSWERS
Question 8 of 12
The patient's ABG analysis is as follows: pH - 7.2; PaCO2 - 60 mm Hg; PaO2 - 73 mm
Hg; HCO3− - 25 mEq/L. The nurse identifies the nursing diagnostic statement of
Impaired Gas Exchange r/t COPD AEB ABG results. Which goal statement should the
nurse include in the plan of care?
Patient's pH value will return to a level between 7.35 and 7.45 within 12 hours.
Patient's oxygen saturation will be > 97% within 12 hours.
Patient will be able to walk 100 feet down the hall with a respiratory rate less than 22
breaths per minute by Day 3 of hospital stay.
The patient will require decreased supplemental oxygen based on assessment data. -
Answer-Patient's pH value will return to a level between 7.35 and 7.45 within 12 hours.
This goal is specific and realistic and is appropriate for the nurse to include in the plan
of care
Question 9 of 12
Which intervention should the nurse include in the plan of care for a patient who is
experiencing respiratory alkalosis?
Preparing for mechanical ventilation
Increasing fluid intake
Facilitating a cough
Breathing into a paper bag - Answer-Breathing into a paper bag
Breathing into a paper bag is an appropriate intervention for a patient who is
experiencing respiratory alkalosis.
Question 10 of 12
Which nursing action is appropriate when providing care to a patient who is
experiencing metabolic alkalosis?
Preparing for mechanical ventilation
Administering the ordered sodium bicarbonate
Initiating seizure precautions
Holding foods rich in potassium - Answer-Initiating seizure precautions
Patients who are experiencing metabolic alkalosis are at risk for seizure activity.
Therefore, this is an appropriate nursing action when providing care to a patient who is
experiencing metabolic alkalosis.
,Question 11 of 12
The nurse is planning a collaborative care conference for a patient diagnosed with an
acid-base imbalance. Which members of the healthcare team should the nurse include
during the acute phase of any acid-base imbalance?
Select all that apply.
Unlicensed assistive personnel (UAP)
Physical therapist (PT)
Primary care provider (PCP)
Respiratory therapist (RT)
Occupational therapist (OT) - Answer-Primary care provider (PCP)
The PCP is an essential member of the collaborative healthcare team who will be
involved in providing patient care during the acute phase of an acid-base imbalance.
Correct
Respiratory therapist (RT)
The RT is an essential member of the collaborative healthcare team who will be
involved with providing patient care during the acute phase of an acid-base imbalance.
Question 12 of 12
Which interventions should the nurse implement for a patient who is experiencing
respiratory acidosis?
Select all that apply.
Increase the rate of IV fluid administration
Encourage deep breathing exercises
Monitor breath sounds
Provide emotional support
Administer prescribed narcotic - Answer-Encourage deep breathing exercises
The nurse can independently encourage the patient to complete deep breathing
exercises.
Correct
Monitor breath sounds
The nurse should monitor the patient's breath sounds due to the current respiratory
status.
Correct
Provide emotional support
The nurse should provide emotional support for the patient who is experiencing an acid-
base imbalance.
Nursing Diagnosis and Planning Related to Electrolyte Imbalances:
Question 1 of 7
The nurse identifies hypokalemia in a patient. Which findings on the nursing
assessment may be associated with this electrolyte imbalance?
Select all that apply.
Bradycardia
Hypertension
Poor muscle tone
Poor skin turgor
,Increased blood glucose levels - Answer-Bradycardia
The heart rate is affected by hypokalemia. Bradycardia is an assessment finding that
may be related to hypokalemia.
Correct
Hypertension
The blood pressure is affected by hypokalemia. Hypertension is an assessment finding
that may be related to hypokalemia.
Correct
Poor muscle tone
The neuromuscular system is affected by hypokalemia. Poor muscle tone is an
assessment finding that may be related to hypokalemia.
Correct
Poor skin turgor
Nausea and vomiting occur with hypokalemia, which leads to dehydration. Poor skin
turgor is an assessment finding that may be related to hypokalemia.
Question 2 of 7
The nurse identifies the nursing diagnosis of Imbalanced nutrition: less than body
requirements related to anorexia, nausea, and vomiting. Which electrolyte imbalance
should the nurse use as the "as evidenced by" portion for this nursing diagnostic
statement?
Hypercalcemia
Hypernatremia
Hyperkalemia
Hypermagnesemia - Answer-Hypercalcemia
Hypercalcemia (high levels of calcium in the blood) is often the cause of anorexia,
nausea, and vomiting. Therefore, this is an appropriate term to use as the "as
evidenced by" portion of the nursing diagnostic statement.
Question 3 of 7
The nurse is providing care to a patient with electrolyte imbalance showing edema and
shortness of breath. Which nursing diagnosis should the nurse include in the updated
patient plan of care?
Imbalanced nutrition: less than body requirements r/t electrolyte imbalance, as
evidenced by shortness of breath
Acute confusion related to electrolyte imbalances, as evidenced by edema and
shortness of breath
Fluid volume excess related to electrolyte imbalances, as evidenced by edema and
shortness of breath
Altered cardiac output related to fluid in the lungs, as evidenced by edema and
shortness of breath - Answer-Fluid volume excess related to electrolyte imbalances, as
evidenced by edema and shortness of breath
This nursing diagnostic statement is accurate because the electrolyte imbalance is
causing the nursing diagnosis of Fluid volume excess, which is manifested by edema
and shortness of breath.
, Question 4 of 7
The nurse identifies the nursing diagnosis Risk for electrolyte imbalance for an older
adult patient experiencing nausea, vomiting, and diarrhea. Which is an accurate goal
statement for the nurse to include in the patient's plan of care?
Patient's serum potassium level will be within the normal range of 3.5-5.0 mEq/L during
the hospitalization.
Patient's serum sodium level will be within the normal range of 1.5-2.0 mEq/L during the
hospitalization.
Patient's serum calcium level will be within the normal range of 135-145 mEq/L during
the hospitalization.
Patient's serum magnesium level will be within the normal range of 8.4-10.2 mg/dL
during the hospitalization. - Answer-Patient's serum potassium level will be within the
normal range of 3.5-5.0 mEq/L during the hospitalization.
This is an accurate goal for the patient as the normal range for potassium is 3.5-5.0
mEq/L.
Question 5 of 7
The nurse is planning care for a patient whose nursing diagnosis is Decreased cardiac
output related to electrolyte imbalance. The NOC for this nursing diagnosis is Cardiac
pump effectiveness. Which indicators should the nurse monitor to determine the
effectiveness of the current plan of care?
Select all that apply.
Apical heart rate and rhythm
Blood pressure
Heart sounds
Serum potassium
Nutrient intake - Answer-Blood pressure
Blood pressure is an indicator used by the nurse to determine the effectiveness of the
plan of care to address the NOC of Cardiac pump effectiveness.
Correct
Heart sounds
Heart sounds is an indicator used by the nurse to determine the effectiveness of the
plan of care to address the NOC of Cardiac pump effectiveness.
Question 6 of 7
Which goal should the nurse include in the plan of care for a patient whose priority
nursing diagnosis is Acute pain related to electrolyte imbalances, as evidenced by
muscle cramping?
Patient's serum electrolyte levels will be normal within 48 hours of implementing
prescribed treatment.
Patient will report a muscle cramp pain rating of no more than 3 on a 1 to 10 numeric
scale within 1 hour of implementing prescribed treatment.
Patient will achieve Pain control during hospitalization.
Patient will consume adequate nourishment during hospitalization, including foods rich
in electrolytes. - Answer-Patient will report a muscle cramp pain rating of no more than
3 on a 1 to 10 numeric scale within 1 hour of implementing prescribed treatment.
