RESP1110 Ch.39 and Ch.42 Questions With Correct
Answers
The nurse will be caring for a patient who is severely malnourished. Laboratory test
results show that the patient's albumin level is critically low. What assessment finding
will then nurse expect to note when assessing the patient?
A. The patient has generalized 3+ pitting edema
B. The patient is confused and disoriented
C. The patient's urine is dark and very concentrated
D. The patient lung sounds are very diminished - Correct Answer Answer: A. The
patient has generalized 3+ pitting edema
The patient's low albumin level will lead to generalized pitting edema because there isn't
enough protein in the blood to keep water within the bloodstream. Lack of oncotic
pressure from low serum albumin leads to edema. The other findings are not related to
malnutrition.
The nurse is reviewing the patient's laboratory results. Which result must be
communicated to the physician immediately?
A. Serum chloride level 85 mEq/L
B. Serum sodium level 134 mEq/L
C. Serum potassium level 6.8 mEq/L
D. Serum magnesium level 2.3 mEq/L - Correct Answer Answer: C. Serum potassium
level 6.8 mEq/L
Normal serum potassium level is 3.5 to 5.0 mEq/L. A serum potassium level of 6.8
mEq/L is very high and puts the patient at risk for cardiac arrhythmais. The potassium
level should be reported to the physician immediately. The chlorine and sodium levels
are slightly low and the magnesium level is slightly elevated.
The nurse is caring for a patient who is at risk for fluid overload due to a history of
congestive heart failure. Which intervention will the nurse teach the patient to perform at
home to monitor fluid balance?
A. "Check to make sure that your urine is a bright yellow color."
B. "Weigh yourself every morning before breakfast."
C. "Count your heart rate every evening before you go to bed."
D. "Drink plain water rather than soda, coffee, or fruit juice." - Correct Answer Answer:
B. "Weigh yourself every morning before breakfast."
Checking the weight every morning before breakfast is a sensitive indicator of the
patient's fluid volume status. Weight gain of 2 kg in 3 days generally indicates fluid
retention and should be reported to the physician.
The nurse is caring for a patient who is admitted to the hospital with diabetic
ketoacidosis. Which assessment finding indicates an attempt made by the patient's
body to correct the pH?
A. The patient's respirations are very deep and rapid.
B. The patient's urine is dark and concentrated.
C. The patient's skin is pale, cool, and diaphoretic.
,D. The patient is sleepy and difficult to arouse. - Correct Answer Answer: A. The
patient's respirations are very deep and rapid.
The patient with diabetic ketoacidosis is in a state of metabolic acidosis. The body will
attempt to compensate for the acidosis by blowing off extra amounts of carbon dioxide
through deep, rapid, respirations. Since carbon dioxide is converted to carbonic acid,
removal of carbon dioxide will help shift the body's pH to a less acidotic state.
The nurse is caring or a patient who takes furosemide (Lasix) daily to treat congestive
heart failure. The nurse will watch for which electrolyte imbalance that may occur due to
this therapy?
A. Hypocalcemia
B. Hypernatremia
C. Hypokalemia
D. Hyperphosphatemia - Correct Answer Answer: C. Hypokalemia
Furosemide is a loop diuretic that causes loss of potassium through the urine. Patients
taking this medication are at risk for hypokalemia, so the nurse should check the
patient's electrolyte values closely, particularly the serum potassium level.
The nurse is caring for a patient who was brought to the ED after overdosing on narcotic
pain medication. The patient was found unresponsive with no respirations. Arterial blood
gases were drawn shortly after the patient's arrival to the hospital. Which results will the
nurse expect to see?
A. pH 7.56, PaCO2 32mm Hg, HCO3 32 mEq/L, Pao2 90 mm Hg
B. pH 7.35, PaCO2 45 mm Hg, HCO3 26 mEq/L, PaO2 70 mm Hg
C. pH 7.45, PaCO2 38 mm Hg, HCO3 28 mEq/L, PaO2 80 mm Hg
D. pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg - Correct Answer
Answer: D. pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg
The patient who overdosed on narcotic pain medication will be in respiratory acidosis
due to respiratory suppression. Low pH of 7.27 and elevated PaCO2 are consistent with
respiratory acidosis as insufficient carbon dioxide is removed from the blood. The low
60 mm Hg PaO2 is due to insufficient oxygen intake.
The nurse is caring for a patient who is admitted to the hospital with dehydration and
gastroenteritis. The patient attempted to walk to the bathroom and fainted right after
getting out of bed. The nurse knows which condition to be the most likely cause of the
patient's collapse?
A. Orthostatic hypotension
B. Circulatory overload
C. Hemolytic reaction
D. Catheter embolism - Correct Answer Answer: A. Orthostatic hypotension
The patient with dehydration is at risk for orthostatic hypotension or falling of the blood
pressure when the patient rises to a standing position. When the blood pressure falls
sufficiently, fainting may occur. The patient should be assisted to rise slowly from a
supine to a sitting position first before slowly getting to his feet. Circulatory overload,
hemolytic anemia, and catheter embolism are unlikely to be causative factors.
, The nurse is caring for a patient whose ABG results reveal the following: pH 7.56,
PaCO2 32 mm Hg, HCO3 42 mEq/L, PaO2 90 mm Hg. Which condition will the nurse
expect to see in the patient's chart as the underlying cause of these results?
A. Gastroenteritis with severe nausea, vomiting, and diarrhea
B. Widespread tissue ischemia caused by cardiogenic shock
C. Respiratory failure caused by pneumonia with pleural effusions
D. Hyperventilation after a panic attack - Correct Answer Answer: A. Gastroenteritis with
severe nausea, vomiting, and diarrhea
Gastroenteritis with severe nausea, vomiting, and diarrhea will lead to a metabolic
alkalosis resulting from loss of electrolytes and acids through emesis and loose stools.
Metabolic alkalosis features the elevated pH of 7.56, elevated HCO3 42 mEq/L, and
normal PaCO2 of 32 mm Hg. Widespread tissue ischemia would lead to metabolic
acidosis with low pH resulting from release of lactic avid from the tissues. Respiratory
failure leads to respiratory acidosis with a low pH and elevated PaCO2 level.
Hyperventilation leads to respiratory alkalosis with an elevated pH and elevated HCO3
level.
The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient
has consumed 250 mL with each of the three meals and had another 150 mL with
medication administration. The patient has received 150 mL of IV fluids during the day.
How many mL of fluid may the patient still consume to stay within the prescribed fluid
restriction?
A. 100 mL
B. 150 mL
C. 250 mL
D. 300 mL - Correct Answer Answer: B. 150 mL
The patient has had an oral fluid intake of 900 mL and an IV fluid intake of 150 mL,
giving a total of 1050 mL. This leaves 150 mL that the patient may consume for the rest
of the evening to stay within the prescribed fluid restriction.
The nurse is caring for a patient who has a history of congestive heart failure. The nurse
includes the diagnosis hypervolemia in the patient's care plan. Which goal statement
has the highest priority for the patient and nurse?
A. The patient's lung sounds will remain clear
B. The patient will have urine output of at least 30 mL/hr
C. The patient will verbalize understanding of fluid restrictions
D. The patient's pitting pedal edema will resolve within 72 hours - Correct Answer
Answer: A. The patient's lung sounds will remain clear
Oxygenation is the highest priority for the patient with congestive heart failure and
hypervolemia. Keeping the patient's lungs clear is the most important goal for the nurse
to consider when caring for this patient.
The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone
secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid
overload. Which IV fluid will the nurse expect to administer to this patient to correct the
patient's fluid imbalance?
Answers
The nurse will be caring for a patient who is severely malnourished. Laboratory test
results show that the patient's albumin level is critically low. What assessment finding
will then nurse expect to note when assessing the patient?
A. The patient has generalized 3+ pitting edema
B. The patient is confused and disoriented
C. The patient's urine is dark and very concentrated
D. The patient lung sounds are very diminished - Correct Answer Answer: A. The
patient has generalized 3+ pitting edema
The patient's low albumin level will lead to generalized pitting edema because there isn't
enough protein in the blood to keep water within the bloodstream. Lack of oncotic
pressure from low serum albumin leads to edema. The other findings are not related to
malnutrition.
The nurse is reviewing the patient's laboratory results. Which result must be
communicated to the physician immediately?
A. Serum chloride level 85 mEq/L
B. Serum sodium level 134 mEq/L
C. Serum potassium level 6.8 mEq/L
D. Serum magnesium level 2.3 mEq/L - Correct Answer Answer: C. Serum potassium
level 6.8 mEq/L
Normal serum potassium level is 3.5 to 5.0 mEq/L. A serum potassium level of 6.8
mEq/L is very high and puts the patient at risk for cardiac arrhythmais. The potassium
level should be reported to the physician immediately. The chlorine and sodium levels
are slightly low and the magnesium level is slightly elevated.
The nurse is caring for a patient who is at risk for fluid overload due to a history of
congestive heart failure. Which intervention will the nurse teach the patient to perform at
home to monitor fluid balance?
A. "Check to make sure that your urine is a bright yellow color."
B. "Weigh yourself every morning before breakfast."
C. "Count your heart rate every evening before you go to bed."
D. "Drink plain water rather than soda, coffee, or fruit juice." - Correct Answer Answer:
B. "Weigh yourself every morning before breakfast."
Checking the weight every morning before breakfast is a sensitive indicator of the
patient's fluid volume status. Weight gain of 2 kg in 3 days generally indicates fluid
retention and should be reported to the physician.
The nurse is caring for a patient who is admitted to the hospital with diabetic
ketoacidosis. Which assessment finding indicates an attempt made by the patient's
body to correct the pH?
A. The patient's respirations are very deep and rapid.
B. The patient's urine is dark and concentrated.
C. The patient's skin is pale, cool, and diaphoretic.
,D. The patient is sleepy and difficult to arouse. - Correct Answer Answer: A. The
patient's respirations are very deep and rapid.
The patient with diabetic ketoacidosis is in a state of metabolic acidosis. The body will
attempt to compensate for the acidosis by blowing off extra amounts of carbon dioxide
through deep, rapid, respirations. Since carbon dioxide is converted to carbonic acid,
removal of carbon dioxide will help shift the body's pH to a less acidotic state.
The nurse is caring or a patient who takes furosemide (Lasix) daily to treat congestive
heart failure. The nurse will watch for which electrolyte imbalance that may occur due to
this therapy?
A. Hypocalcemia
B. Hypernatremia
C. Hypokalemia
D. Hyperphosphatemia - Correct Answer Answer: C. Hypokalemia
Furosemide is a loop diuretic that causes loss of potassium through the urine. Patients
taking this medication are at risk for hypokalemia, so the nurse should check the
patient's electrolyte values closely, particularly the serum potassium level.
The nurse is caring for a patient who was brought to the ED after overdosing on narcotic
pain medication. The patient was found unresponsive with no respirations. Arterial blood
gases were drawn shortly after the patient's arrival to the hospital. Which results will the
nurse expect to see?
A. pH 7.56, PaCO2 32mm Hg, HCO3 32 mEq/L, Pao2 90 mm Hg
B. pH 7.35, PaCO2 45 mm Hg, HCO3 26 mEq/L, PaO2 70 mm Hg
C. pH 7.45, PaCO2 38 mm Hg, HCO3 28 mEq/L, PaO2 80 mm Hg
D. pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg - Correct Answer
Answer: D. pH 7.27, PaCO2 58 mm Hg, HCO3 24 mEq/L, PaO2 60 mm Hg
The patient who overdosed on narcotic pain medication will be in respiratory acidosis
due to respiratory suppression. Low pH of 7.27 and elevated PaCO2 are consistent with
respiratory acidosis as insufficient carbon dioxide is removed from the blood. The low
60 mm Hg PaO2 is due to insufficient oxygen intake.
The nurse is caring for a patient who is admitted to the hospital with dehydration and
gastroenteritis. The patient attempted to walk to the bathroom and fainted right after
getting out of bed. The nurse knows which condition to be the most likely cause of the
patient's collapse?
A. Orthostatic hypotension
B. Circulatory overload
C. Hemolytic reaction
D. Catheter embolism - Correct Answer Answer: A. Orthostatic hypotension
The patient with dehydration is at risk for orthostatic hypotension or falling of the blood
pressure when the patient rises to a standing position. When the blood pressure falls
sufficiently, fainting may occur. The patient should be assisted to rise slowly from a
supine to a sitting position first before slowly getting to his feet. Circulatory overload,
hemolytic anemia, and catheter embolism are unlikely to be causative factors.
, The nurse is caring for a patient whose ABG results reveal the following: pH 7.56,
PaCO2 32 mm Hg, HCO3 42 mEq/L, PaO2 90 mm Hg. Which condition will the nurse
expect to see in the patient's chart as the underlying cause of these results?
A. Gastroenteritis with severe nausea, vomiting, and diarrhea
B. Widespread tissue ischemia caused by cardiogenic shock
C. Respiratory failure caused by pneumonia with pleural effusions
D. Hyperventilation after a panic attack - Correct Answer Answer: A. Gastroenteritis with
severe nausea, vomiting, and diarrhea
Gastroenteritis with severe nausea, vomiting, and diarrhea will lead to a metabolic
alkalosis resulting from loss of electrolytes and acids through emesis and loose stools.
Metabolic alkalosis features the elevated pH of 7.56, elevated HCO3 42 mEq/L, and
normal PaCO2 of 32 mm Hg. Widespread tissue ischemia would lead to metabolic
acidosis with low pH resulting from release of lactic avid from the tissues. Respiratory
failure leads to respiratory acidosis with a low pH and elevated PaCO2 level.
Hyperventilation leads to respiratory alkalosis with an elevated pH and elevated HCO3
level.
The nurse is caring for a patient who has a 1200 mL daily fluid restriction. The patient
has consumed 250 mL with each of the three meals and had another 150 mL with
medication administration. The patient has received 150 mL of IV fluids during the day.
How many mL of fluid may the patient still consume to stay within the prescribed fluid
restriction?
A. 100 mL
B. 150 mL
C. 250 mL
D. 300 mL - Correct Answer Answer: B. 150 mL
The patient has had an oral fluid intake of 900 mL and an IV fluid intake of 150 mL,
giving a total of 1050 mL. This leaves 150 mL that the patient may consume for the rest
of the evening to stay within the prescribed fluid restriction.
The nurse is caring for a patient who has a history of congestive heart failure. The nurse
includes the diagnosis hypervolemia in the patient's care plan. Which goal statement
has the highest priority for the patient and nurse?
A. The patient's lung sounds will remain clear
B. The patient will have urine output of at least 30 mL/hr
C. The patient will verbalize understanding of fluid restrictions
D. The patient's pitting pedal edema will resolve within 72 hours - Correct Answer
Answer: A. The patient's lung sounds will remain clear
Oxygenation is the highest priority for the patient with congestive heart failure and
hypervolemia. Keeping the patient's lungs clear is the most important goal for the nurse
to consider when caring for this patient.
The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone
secretion (SIADH) who has a serum sodium level of 118 mEq/dL and symptoms of fluid
overload. Which IV fluid will the nurse expect to administer to this patient to correct the
patient's fluid imbalance?
