NUR 2349 PN1 Exam 3
•
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 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
, NUR 2349 PN1 Exam 3
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.
Monitor I&O daily.
C.
Encourage fluid intake.
, D.
Monitor electrolyte balance.
Response Hypovolemia occurs when more fluid is lost than is taken into the body.
Feedback: 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: C.
"The medications that I take will help prevent my body from attacking
my new kidney."
Correct
Answer: C.
"The medications that I take will help prevent my body from attacking
my new kidney."
Response
Feedback: 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
•
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 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
, NUR 2349 PN1 Exam 3
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.
Monitor I&O daily.
C.
Encourage fluid intake.
, D.
Monitor electrolyte balance.
Response Hypovolemia occurs when more fluid is lost than is taken into the body.
Feedback: 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: C.
"The medications that I take will help prevent my body from attacking
my new kidney."
Correct
Answer: C.
"The medications that I take will help prevent my body from attacking
my new kidney."
Response
Feedback: 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
