Chapter 15 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 15

Question 1

Type: MCSA

When caring for an elderly patient who is intermittently confused, what is the nurses primary concern regarding fluid and electrolytes?

1. Risk of dehydration

2. Risk of kidney damage

3. Risk of stroke

4. Risk of bleeding

Correct Answer: 1

Rationale 1: As an adult ages, the perception of thirst declines. In an older patient with an altered level of consciousness, there is an increased risk of dehydration and high serum osmolality.

Rationale 2: The risk of kidney damage is not specifically related to aging or fluid and electrolyte issues.

Rationale 3: The risk of stroke is not specifically related to aging or fluid and electrolyte issues.

Rationale 4: The risk of bleeding is not specifically related to aging or fluid and electrolyte issues.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-1

Question 2

Type: MCSA

A patient experiencing multisystem fluid volume deficit has tachycardia and decreased urine output. The nurse realizes these findings are most likely a direct result of which factor?

1. The bodys natural compensatory mechanisms

2. Pharmacologic effects of a diuretic

3. Effects of rapidly infused intravenous fluids

4. Cardiac failure

Correct Answer: 1

Rationale 1: The bodys vasoconstrictive compensatory reactions are responsible for the symptoms. The body naturally attempts to conserve fluid internally specifically for the brain and heart.

Rationale 2: A diuretic would cause further fluid loss and is contraindicated.

Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output.

Rationale 4: The manifestations reported are not indicative of cardiac failure in this patient.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-1

Question 3

Type: MCSA

A pregnant patient is admitted with excessive thirst, increased urination, and a medical diagnosis of diabetes insipidus. The nurse chooses which nursing diagnosis as most appropriate?

1. Risk for Imbalanced Fluid Volume

2. Excess Fluid Volume

3. Imbalanced Nutrition

4. Ineffective Tissue Perfusion

Correct Answer: 1

Rationale 1: The patient with excessive thirst, increased urination, and a medical diagnosis of diabetes insipidus is at risk for Imbalanced Fluid Volume due to excess volume loss that can increase the serum levels of sodium.

Rationale 2: Excess Fluid Volume is not an issue for patients with diabetes insipidus, especially during the early stages of treatment.

Rationale 3: Imbalanced Nutrition is not supported by the assessment data provided.

Rationale 4: Ineffective Tissue Perfusion is not supported by the assessment data provided.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-2

Question 4

Type: MCSA

An adult patient recovering from surgery has an indwelling urinary catheter. The nurse would contact the patients primary health care provider with which 24-hour urine output volume?

1. 600 milliliters

2. 750 milliliters

3. 1,000 milliliters

4. 1,200 milliliters

Correct Answer: 1

Rationale 1: A urine output of less than 30 milliliters per hour must be reported to the primary health care provider. This indicates inadequate renal perfusion, which places the patient at increased risk for acute renal failure and inadequate tissue perfusion. A minimum of 720 milliliters over a 24-hour period is desired (30 milliliters multiplied by 24 hours equals 720 milliliters per 24 hours).

Rationale 2: 750 mL is above the minimum desired level of 30 mL per hour.

Rationale 3: 1,000 mL is above the minimum desired level of 30 mL per hour.

Rationale 4: 1,200 mL is above the minimum desired level of 30 mL per hour.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-2

Question 5

Type: MCSA

A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will mostly likely need which precautions implemented?

1. Seizure precautions

2. Infection precautions

3. Neutropenic precautions

4. High-risk fall precautions

Correct Answer: 1

Rationale 1: Severe hyponatremia can lead to seizures. Seizure precautions would include a quiet environment, raised side rails, and having an oral airway at the bedside.

Rationale 2: Infection precautions are not specifically indicated for a patient with hyponatremia.

Rationale 3: Neutropenic precautions are not specifically indicated for a patient with hyponatremia.

Rationale 4: High-risk fall precautions are not specifically indicated for a patient with hyponatremia.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-5

Question 6

Type: MCSA

A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which imbalance?

1. Hyperkalemia

2. Hypokalemia

3. Hypercalcemia

4. Hypocalcemia

Correct Answer: 1

Rationale 1: Hyperkalemia is defined as serum potassium level greater than 5.0 mEq/L. Decreased potassium excretion is seen with potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness and ECG changes.

Rationale 2: Hypokalemia is seen in nonpotassium sparing diuretics such as furosemide.

Rationale 3: Hypercalcemia has been associated with thiazide diuretics.

Rationale 4: Hypocalcemia is seen in patients who have received many units of citrated blood and is not associated with diuretic use.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-1

Question 7

Type: MCSA

The nurse is planning care for a patient with fluid volume overload and hyponatremia. Which intervention should be included in this patients plan of care?

1. Restrict fluids.

2. Administer intravenous fluids.

3. Provide Kayexalate.

4. Administer intravenous normal saline with furosemide.

Correct Answer: 1

Rationale 1: The nursing care for a patient with hyponatremia depends on the cause. Restriction of fluids to 1,000 mL/day is usually implemented to assist sodium increase and to prevent the sodium level from dropping further due to dilution.

Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit and hypernatremia.

Rationale 3: Kayexalate is used in patients with hyperkalemia.

Rationale 4: Normal saline with furosemide is administered to increase calcium secretion.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-2

Question 8

Type: MCSA

When caring for a patient diagnosed with hypocalcemia, the nurse would also assess for which other finding?

1. Other electrolyte disturbances

2. Hypertension

3. Visual disturbances

4. Drug toxicity

Correct Answer: 1

Rationale 1: The patient diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels.

Rationale 2: The patient with hypocalcemia may exhibit hypotension, not hypertension.

Rationale 3: Visual disturbances do not occur with hypocalcemia.

Rationale 4: Hypercalcemia is more commonly caused by drug toxicities.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-5

Question 9

Type: MCSA

A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. Which intervention should the nurse include in this patients plan of care?

1. Request a dietitian consult to select foods high in phosphorous.

2. Provide aluminum hydroxide antacids as prescribed.

3. Instruct the patient to avoid poultry, peanuts, and seeds.

4. Instruct the patient to avoid the intake of sodium phosphate.

Correct Answer: 1

Rationale 1: Treatment of hypophosphatemia includes treating the underlying cause and promoting a high-phosphate diet, especially milk if it is tolerated. Other foods high in phosphate are dried beans and peas, eggs, fish, organ meats, Brazil nuts and peanuts, poultry, seeds, and whole grains.

Rationale 2: Phosphate-binding antacids, such as aluminum hydroxide, should be avoided.

Rationale 3: Poultry, peanuts, and seeds are part of a high-phosphate diet.

Rationale 4: Mild hypophosphatemia may be corrected with oral supplements, such as sodium phosphate.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-5

Question 10

Type: MCSA

When analyzing an arterial blood gas report of a patient with COPD and respiratory acidosis, the nurse anticipates that compensation will develop through which mechanism?

1. The kidneys retain bicarbonate.

2. The kidneys excrete bicarbonate.

3. The lungs will retain carbon dioxide.

4. The lungs will excrete carbon dioxide.

Correct Answer: 1

Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate.

Rationale 2: Excreting bicarbonate causes acidosis to develop.

Rationale 3: Retaining carbon dioxide causes respiratory acidosis.

Rationale 4: Excreting carbon dioxide causes respiratory alkalosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 15-4

Question 11

Type: MCSA

The nurse is caring for a patient diagnosed with renal failure. Which compensation does the nurse expect for the acid-base disturbance found in patients with renal failure?

1. The patient breathes rapidly to eliminate carbon dioxide.

2. The patient will retain bicarbonate in excess of normal.

3. The pH will decrease from the present value.

4. The patients oxygen saturation level will improve.

Correct Answer: 1

Rationale 1: In metabolic acidosis, compensation is accomplished through increased ventilation or blowing off CO2. This raises the pH by eliminating the volatile respiratory acid and compensates for the acidosis.

Rationale 2: Because compensation must be performed by the system other than the affected system, the patient cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure is a lower than normal bicarbonate value.

Rationale 3: Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the disease process, not the compensation.

Rationale 4: Oxygenation disturbance is not part of the acid-base status of the patient with renal failure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-3

Question 12

Type: MCSA

The nurse would assess specifically for metabolic alkalosis in which patient?

1. A patient admitted for treatment of bulimia

2. A patient who has been on dialysis for 2 months

3. A patient with a nonhealing venous stasis ulcer

4. A patient with newly diagnosed with COPD

Correct Answer: 1

Rationale 1: Metabolic alkalosis is caused by vomiting, diuretic therapy, or nasogastric suction, among others. A patient with bulimia may engage in vomiting or the indiscriminate use of diuretics.

Rationale 2: A patient receiving dialysis has kidney failure, which causes metabolic acidosis.

Rationale 3: A venous stasis ulcer does not lead to an acid-base disorder.

Rationale 4: The patient diagnosed with COPD typically has hypercapnea and respiratory acidosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-3

Question 13

Type: MCSA

The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include: pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. The nurse would anticipate which initial intervention to correct this problem?

1. Encourage the patient to breathe in and out slowly into a paper bag.

2. Immediately administer oxygen via a mask and monitor oxygen saturation.

3. Start an intravenous fluid bolus using isotonic fluids.

4. Administer intravenous sodium bicarbonate.

Correct Answer: 1

Rationale 1: This patient is exhibiting signs of hyperventilation, which is confirmed with the blood gas results of respiratory alkalosis. Breathing into a paper bag will help the patient retain carbon dioxide and lower oxygen levels to normal, correcting the cause of the problem.

Rationale 2: The oxygen levels are high, so oxygen is not indicated and would exacerbate the problem if given.

Rationale 3: Not enough information is given to determine the need for intravenous fluids.

Rationale 4: Bicarbonate would be contraindicated as the pH is already high.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-2

Question 14

Type: MCSA

An elderly patient does not complain of thirst. Which information would the nurse evaluate to determine if the patient is dehydrated?

1. Magnesium level

2. Chest X-ray

3. Urine osmolality

4. Brain scan

Correct Answer: 3

Rationale 1: The magnesium level is not a sensitive indicator of fluid status.

Rationale 2: A chest X-ray would be more useful in discovering if the patient is overhydrated.

Rationale 3: The thirst mechanism declines with aging, which makes older adults more vulnerable to dehydration and hyperosmolality. Urine osmolality would help to determine the need for more detailed or invasive testing.

Rationale 4: There is no data to support the need for a brain scan.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-6

Question 15

Type: FIB

A clinic patient is short of breath and has ankle edema. Todays weight is 8 pounds heavier that last weeks weight. The nurse determines that the patient could have retained ______ pints of fluid.

Standard Text:

Correct Answer: 8

Rationale : Each pint of fluid weighs 1 pound.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 15-1

Question 16

Type: MCSA

A postoperative patient is diagnosed with fluid volume overload. Which assessment would the nurse attribute to this diagnosis?

1. The patient has poor skin turgor.

2. The patient has decreased urine output.

3. The patient reports sleeping on two pillows.

4. The patients laboratory testing reveals concentrated hemoglobin and hematocrit levels.

Correct Answer: 3

Rationale 1: Poor skin turgor is associated with fluid volume deficit.

Rationale 2: Decreased urine output is associated with fluid volume deficit.

Rationale 3: Fluid volume overload can result in difficulty breathing when the patient tries to sleep. The patient may compensate for this condition by sleeping on more than one pillow.

Rationale 4: Increased hemoglobin and hematocrit values are associated with fluid volume deficit.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-6

Question 17

Type: MCSA

An elderly patient reports having watery diarrhea for several days before coming to the clinic. This morning the patient is lethargic and confused. The nurse would assess this patient for which electrolyte imbalance?

1. Hypernatremia

2. Hyponatremia

3. Hypermagnesemia

4. Hyperkalemia

Correct Answer: 2

Rationale 1: Hypernatremia is associated with fluid retention and overload. It is unlikely that this patient has fluid volume overload.

Rationale 2: Watery diarrhea contributes to the loss of sodium. The lethargy and confusion are manifestations of a low serum sodium level.

Rationale 3: Hypermagnesemia is found in patients with renal failure or adrenal insufficiency. It is also seen in obstetric settings where women receive IV magnesium to decrease symptoms of pregnancy-induced hypertension.

Rationale 4: A patient with hyperkalemia is more likely to experience cardiac dysrhythmias.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-6

Question 18

Type: MCSA

A patient is diagnosed with hypokalemia. Which medication order would the nurse anticipate?

1. Potassium 40 mEq IV push

2. Potassium 40 mEq added to the next liter of IV fluids

3. Potassium 40 mEq by rectal suppository

4. Potassium 40 mEq IM

Correct Answer: 2

Rationale 1: Potassium should never be given IV push.

Rationale 2: The intravenous route is the recommended route for diluted potassium.

Rationale 3: Potassium is irritating to tissues and is not given rectally.

Rationale 4: Potassium is irritating to tissues and is not given IM.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-2

Question 19

Type: MCSA

A patients blood gases show a pH of 7.53 and bicarbonate level of 36 mEq/L. The nurse prepares to treat this patient for which acid-base disorder?

1. Respiratory acidosis

2. Metabolic acidosis

3. Respiratory alkalosis

4. Metabolic alkalosis

Correct Answer: 4

Rationale 1: Respiratory acidosis is consistent with a pH lower than 7.35.

Rationale 2: Metabolic acidosis is consistent with pH lower than 7.35.

Rationale 3: Respiratory alkalosis is associated with a pH greater than 7.45 and a PaCO2 of less than 35 mmHG. It is caused by respiratory-related conditions.

Rationale 4: When the patient is in metabolic alkalosis, arterial blood gases (ABGs) show a pH greater than 7.45 and bicarbonate level greater than 26 mEq/L.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-4

Question 20

Type: MCSA

An elderly postoperative patient is demonstrating lethargy, confusion, and a respiratory rate of 8 per minute. The nurse sees that the last dose of pain medication administered via a patient-controlled anesthesia (PCA) pump was less than 30 minutes ago. This patient is most likely experiencing which acid-base disorder?

1. Respiratory acidosis

2. Metabolic acidosis

3. Respiratory alkalosis

4. Metabolic alkalosis

Correct Answer: 1

Rationale 1: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdose of narcotic or sedative medications can lead to this condition.

Rationale 2: The patients condition is respiratory, not metabolic, in nature.

Rationale 3: Respiratory alkalosis is more likely to be caused by overventilation, resulting in the reduction of carbon dioxide.

Rationale 4: The patients condition is respiratory, not metabolic, in nature.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 15-4

Question 21

Type: MCMA

Which patients would the nurse monitor most closely for the development of hypercalcemia?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. A patient with a malignancy

2. A patient taking lithium

3. A patient who uses sunscreen to excess

4. A patient with hyperparathyroidism

5. A patient on complete bed rest

Correct Answer: 1,2,4,5

Rationale 1: Patients with malignancy are at risk for development of hypercalcemia due to destruction of bone or the production of hormone-like substances by the malignancy.

Rationale 2: The use of lithium and overuse of antacids can result in hypercalcemia. Hypercalcemia can result from hyperparathyroidism, which causes release of calcium from the bones, increased calcium absorption in the intestines, and retention of calcium by the kidneys.

Rationale 3: The patient who uses sunscreen to excess is more likely to have a vitamin D deficiency, which would result in hypocalcemia.

Rationale 4: Hypercalcemia can result from hyperparathyroidism, which causes release of calcium from the bones, increased calcium absorption in the intestines, and retention of calcium by the kidneys.

Rationale 5: Prolonged bed rest can result in mobilization of bone calcium into the blood.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-6

Question 22

Type: MCMA

A patient who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Bananas

2. Seafood

3. White rice

4. Lean red meat

5. Chocolate

Correct Answer: 1,2,5

Rationale 1: A serum magnesium level of 1.4 mg/dL suggests mild hypomagnesemia, so this patient should be counseled to eat foods high in magnesium, including bananas.

Rationale 2: A serum magnesium level of 1.4 mg/dL suggests mild hypomagnesemia, so this patient should be counseled to eat foods high in magnesium, including seafood.

Rationale 3: A serum magnesium level of 1.4 mg/dL suggests mild hypomagnesemia, so this patient should be counseled to eat foods high in magnesium. White rice is not high in magnesium.

Rationale 4: A serum magnesium level of 1.4 mg/dL suggests mild hypomagnesemia, so this patient should be counseled to eat foods high in magnesium. Lean red meat is not high in magnesium.

Rationale 5: A serum magnesium level of 1.4 mg/dL suggests mild hypomagnesemia, so this patient should be counseled to eat foods high in magnesium, including chocolate.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-6

Question 23

Type: MCMA

The patient has a serum phosphate level of 4.7 mg/dL. Which interdisciplinary treatments would the nurse expect for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Correction of calcium level

2. Calcium-containing antacids

3. IV potassium phosphate

4. Higher milk intake

5. Increased vitamin D intake

Correct Answer: 1,2

Rationale 1: Correcting hypocalcemia may reduce the phosphate level.

Rationale 2: A serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Calcium-containing antacids bind the phosphate for excretion through the GI tract.

Rationale 3: A serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV potassium phosphate is a treatment for low phosphate.

Rationale 4: A serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Milk is a high-phosphate food and should be discouraged.

Rationale 5: A serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Excess vitamin D increases phosphate absorption and can lead to hyperphosphatemia.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 15-6

Question 24

Type: MCMA

A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea and vomiting. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. Which other assessment findings would the nurse anticipate in this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Abdominal pain

2. Visual changes

3. Dysrhythmias

4. Kussmaul respirations

5. Positive Chvosteks sign

Correct Answer: 1,2,3,4

Rationale 1: Abdominal pain is often experienced by patients with this acid-base imbalance.

Rationale 2: Visual changes may occur as a result of this acid-base imbalance.

Rationale 3: Dysrhythmias such as ventricular tachycardia may occur as a result of this acid-base imbalance.

Rationale 4: Kussmaul respirations occur as the patient tries to compensate for this acid-base imbalance.

Rationale 5: A positive Chvosteks sign is associated with metabolic alkalosis, not metabolic acidosis.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-5

Question 25

Type: MCMA

The nurse is discussing respiratory and metabolic acids and bases. Which statements would the nurse supervisor evaluate as indicating that the nurse needs more information?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. When water combines with carbon dioxide, carbonic acid is produced.

2. Carbon dioxide is a potential acid that is excreted through the lungs.

3. Body metabolism produces lactic acids, which are constantly eliminated in the lungs.

4. Sodium bicarbonate buffers the blood by removing hydrogen ions from the blood.

5. Carbonic acid dissociates into sodium and bicarbonate.

Correct Answer: 3

Rationale 1: Water combines with carbon dioxide to form carbonic acid. This statement indicates understanding of this process.

Rationale 2: Carbon dioxide can be thought of as a potential acid. This statement indicates understanding of this process.

Rationale 3: Lactic acids occur during anaerobic metabolism and are eliminated through the kidneys and the liver.

Rationale 4: Sodium bicarbonate removes hydrogen ions when added to the blood. This statement indicates understanding of the process.

Rationale 5: Carbonic acid dissociates into hydrogen and bicarbonate.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 15-3

Question 26

Type: MCMA

A patient is found to be in respiratory acidosis. The nurse plans care based on which physiological processes?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The pH is low.

2. Carbon dioxide is low.

3. The kidneys are attempting to conserve bicarbonate.

4. Potassium is being displaced from cells.

5. A base excess exists.

Correct Answer: 1,3,4

Rationale 1: Acidosis means the pH is low.

Rationale 2: The carbon dioxide is high.

Rationale 3: The kidneys are conserving bicarbonate and excreting hydrogen ions.

Rationale 4: Potassium is moving from cells into the serum, resulting in hyperkalemia.

Rationale 5: Metabolic alkalosis is characterized by a base excess.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-3

Question 27

Type: MCSA

The nurse is caring for a patient with diabetic ketoacidosis (DKA) who presents with polyuria, abdominal pain, vomiting, and flushed skin. Which clinical manifestation suggests compensation for the acid-base disorder?

1. The patient presents with vomiting.

2. The patient has a respiratory rate of 28 with deep inspirations.

3. The patient has a urine output of 20 mL over the last hour.

4. The patient demonstrates shallow respirations and decreased excursion.

Correct Answer: 2

Rationale 1: Vomiting is a symptom of DKA, not a compensatory mechanism.

Rationale 2: The patient responds to DKA, a type of metabolic acidosis, with increased rate and depth of breathing known as Kussmaul breathing. This compensatory mechanism causes the patient to blow off or exhale CO2, a respiratory acid, to increase the pH in an attempt to return to normal acid-base status.

Rationale 3: Patients with DKA may have dehydration and decreased renal perfusion secondary to polyuria, but this is part of the syndrome, not compensation.

Rationale 4: Shallow breathing with decreased excursion causes respiratory acidosis, which would worsen the situation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-6

Question 28

Type: MCMA

A patients arterial blood gases reveal a pH of 7.49. The nurse would continue to analyze these results based on which evaluation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient may have respiratory acidosis.

2. The patient may have respiratory alkalosis.

3. The patient may have metabolic acidosis.

4. The patient may have metabolic alkalosis.

5. The patient has normal blood gases.

Correct Answer: 2,4

Rationale 1: A pH of 7.49 rules out respiratory acidosis.

Rationale 2: A pH of 7.49 is alkalotic.

Rationale 3: A pH of 7.49 rules out metabolic acidosis.

Rationale 4: A pH of 7.49 is alkalotic.

Rationale 5: A pH of 7.49 is not normal.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-4

Question 29

Type: MCMA

A patient was admitted to an acute care unit with weakness and complaints of dizziness. Dehydration is suspected as the cause. Which laboratory findings would the nurse evaluate as supporting that diagnosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hematocrit of 50%

2. Serum sodium of 132 mEq/L

3. Serum potassium of 5.1 mEq/L

4. Serum bicarbonate of 22 mEq/L

5. Serum osmolality of 320 mOsm/kg

Correct Answer: 1,3,5

Rationale 1: Dehydration can result in high hematocrit.

Rationale 2: A low serum sodium level would be expected in overhydration.

Rationale 3: Dehydration can result in high serum potassium levels.

Rationale 4: Low serum bicarbonate is a result of overhydration.

Rationale 5: Dehydration can result in high serum osmolality.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 15-1

Question 30

Type: FIB

The nurse would assess for dehydration if the patients urine specific gravity is higher than ________.

Standard Text:

Correct Answer: 1.030

Rationale : A urine specific gravity over 1.030 occurs in dehydration.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 15-1

 

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