exam 4 fundamentals practice questions

To adequately assess the quality of a patient's pain, which question would be appropriate? A. "Is it a sharp pain or a dull pain?" B. "Tell me what your pain feels like." C. "Is your pain a crushing sensation?" D. "How long have you had this pain?"

B

Patient-controlled analgesia (PCA) effectiveness is evaluated by: A. The number of minutes on the lockout interval B. How large a loading dose is required to relieve pain C. The client's indicating that pain is a 1 on a scale of 1 to 10 D. When the client is sleeping

C

A client with a small bowel obstruction has had a nasogastric tube connected to low intermittent suction for two days. The nurse should monitor for clinical manifestations of which acid-base disorder? A. Respiratory Alkalosis B. Respiratory Acidosis C. Metabolic Alkalosis D. Metabolic Acidosis

C. Clients with gastric suctioning can lose hydrogen ions resulting in a metabolic alkalosis.

During an assessment, the nurse becomes concerned that a client is at risk for developing metabolic alkalosis. What did the nurse assess that caused this concern?A) Daily ingestion of a banana with breakfast B) Daily weight consistent C) Daily use of sodium bicarbonate for gastric upset D) Daily use of prescribed NSAIDs for arthritic pain

C. Excess bicarbonate usually occurs as a result of ingesting antacids that contain bicarbonate, such as soda bicarbonate or Alka-SeltzerTM. Daily ingestion of a banana would prevent the development of hypokalemia from the daily use of sodium bicarbonate. Consistent daily weights would indicate fluid balance. Daily use of NSAIDs would not support the development of metabolic alkalosis.)

A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder? A. Bradycardia and hyperactivity B. Decreased respiratory rate and depth C. Headache, restlessness, and confusion D. Bradypnea, dizziness, and paresthesias

C. When a client is experiencing respiratory acidosis, the respiratory rate and depth increase in an attempt to compensate. The client also experiences headache; restlessness; mental status changes, such as drowsiness and confusion; visual disturbances; diaphoresis; cyanosis as the hypoxia becomes more acute; hyperkalemia; rapid, irregular pulse; and dysrhythmias. Options 1, 2, and 4 are not specifically associated with this disorder.

A client's baseline vital signs are as follows: temperature 98.8° F oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103° F. Which corresponding respiratory rate should the nurse anticipate in this client as part of the body's response to the change in status? A. Respiratory rate of 12 breaths/min B. Respiratory rate of 16 breaths/min C. Respiratory rate of 18 breaths/min D. Respiratory rate of 22 breaths/min

D

A first day postoperative client on a PCA pump reports that the pain control is inadequate. What is the first action you should take? A. Deliver the bolus dose per standing order. B. Contact the physician to increase the dose. C. Try non-pharmacological comfort measures. D. Assess the pain for location, quality, and intensity.

D

A nurse is assessing a client experiencing acute pain. Which characteristics is more common with acute pain than with chronic pain? A. Self- focusing B. Sleep disturbances C. Guarding behaviors D. Variations in vital signs

D

A nurse is assigned to the care of a client hospitalized with a diagnosis of hypothermia. The nurse anticipates that the client will exhibit which findings on assessment of vital signs? A. Increased heart rate and increased blood pressure B. Increased heart rate and decreased blood pressure C. Decreased heart rate and increased blood pressure D. Decreased heart rate and decreased blood pressure

D

pH 7.57, PaCÓ 22, HCǑ- 17 A. Respiratory Acidosis, Partially Compensated B. Respiratory Alkalosis, Uncompensated C. Metabolic Acidosis, Partially Compensated D. Respiratory Alkalosis, Partially Compensated

D

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao2 = 72 mm Hg (72 mm Hg), Paco2 = 32 mmHg (32 mm Hg), and HCO3- = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make? A. The client has acidotic blood. B. The client is probably overreacting. C. The client is fluid volume overloaded. D. The client is probably hyperventilating.

D. The ABG values are abnormal, which supports a physiological problem. The ABGs indicate respiratory alkalosis as a result of hyperventilating, not acidosis. Concluding that the client is overreacting is an insufficient analysis. No conclusion can be made about a client's fluid volume status from the information provided.

A client develops acute renal failure and a resulting metabolic acidosis. The respiratory system compensates by: A. Hypoventilating and increasing the bicarbonate in the bloodstream B. Alternating periods of deep versus shallow breaths to maintain homeostasis of the serum pH C. Hyperventilating to decrease the serum CO2 and thereby raise the pH D. Expanding the lung tissues to their fullest, which increases the inspiratory reserve volumes to provide more oxygen to the tissues

C

Abnormal processing of sensory input by the peripheral or central nervous system; treatment usually includes adjuvant & analgesics: A. Nociceptive pain B. Somatic pain C. Visceral pain D. Neuropathic pain

D

Dave, a 6-year-old boy, was rushed to the hospital following her mother's complaint that her son has been vomiting, nauseated and has overall weakness. After a series of tests, the nurse notes the laboratory results: potassium: 2.9 mEq. Which primary acid-base imbalance is this boy at risk for if medical intervention is not carried out? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

D

A cigarette vendor was brought to the emergency department of a hospital after she fell into the ground and hurt her left leg. She is noted to be tachycardic and tachypneic. Painkillers were carried out to lessen her pain. Suddenly, she started complaining that she is still in pain and now experiencing muscle cramps, tingling, and paraesthesia. Measurement of arterial blood gas reveals pH 7.6, PaO2 120 mm Hg, PaCO2 31 mm Hg, and HCO3 25 mmol/L. What does this mean? A. Respiratory Alkalosis, Uncompensated B. Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated

A

A home care nurse notes in the assessment that an older adult expresses anxiety and fatigue. The client sleeps 3 hours at a time at maximum and has had a 10 lb weight loss. Which of the following interventions is priority? A) Assess the client's level and intensity of pain. B) Interview the family. C) Perform an assessment of vital signs. D) Weigh the client.

A

A nurse is caring for a 24 year old one day post op repair of a tib/fib fracture. The arterial blood gases come back as pH 7.55, PaCO2 28 mmHg, HCO3 22 mEq/L, and PaO2 86 mmHg. The nurse interprets these blood gases as: A.Respiratory alkalosis B.Respiratory acidosis C.Metabolic alkalosis D.Metabolic acidosis

A

Which of the following nursing activities is of highest priority for maintaining medical asepsis? A. Washing hands B. Donning gloves C. Wearing a gown D. Wearing a face mask

A

Which one of the following instructions is crucial for the nurse to give to both family members and the patient who is about to be started on a patient-controlled analgesia (PCA) of morphine? A. Only the patient should push the button. B. Do not use the PCA until the pain is severe. C. The PCA prevents overdoses from occurring. D. Notify the nurse when the button is pushed.

A

pH 7.45, PaCÓ 50, HCǑ- 30 A. Metabolic Alkalosis, Fully Compensated B. Respiratory Alkalosis, Fully Compensated C. Metabolic Alkalosis, Partially Compensated D. Respiratory Acidosis, Partially Compensated

A

pH 7.6, PaCÓ 53, HCǑ- 38 A. Metabolic Alkalosis, Partially Compensated B. Metabolic Alkalosis, Fully Compensated C. Respiratory Acidosis, Partially Compensated D. Respiratory Alkalosis, Fully Compensated

A

A client is brought to the Emergency Department after passing out in a local department store. The client has been fasting and has ketones in the urine. Which acid-base imbalance would the nurse expect to assess in this client? A) Metabolic acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Respiratory acidosis

A A client who is fasting is at risk for development of metabolic acidosis. The body recognizes fasting as starvation and begins to metabolize its own proteins into ketones, which are metabolic acids. Starvation would not result in respiratory acidosis or alkalosis or in metabolic alkalosis.)

A nurse assesses a client who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.32, PaO2 85 mm Hg, PaCO2 34 mm Hg, and HCO3 16 mEq/L. What action should the nurse take next? A. Assess client's rate, rhythm, and depth of respiration. B. Measure the client's pulse and blood pressure. C. Document the findings and continue to monitor. D. Notify the physician as soon as possible.

A. Progressive skeletal muscle weakness is associated with increasing severity of acidosis. Muscle weakness can lead to severe respiratory insufficiency. Acidosis does lead to dysrhythmias (due to hyperkalemia), but these would best be assessed with cardiac monitoring. Findings should be documented, but simply continuing to monitor is not sufficient. Before notifying the physician, the nurse must have more data to report.

The nurse is caring for a client admitted with renal failure and metabolic acidosis. Which of the following signs would indicate to the nurse that planned interventions to relieve the metabolic acidosis have been effective? A) Decreased respiratory depth B) Palpitations C) Increased deep tendon reflexes D) Respiratory rate of 38

A. The client with metabolic acidosis will have an increased respiratory rate and depth. Signs that care has been effective would include a decrease in the rate and depth of respirations. An increased respiratory rate, as indicated by a respiratory rate of 38, would indicate continued metabolic acidosis. Increased deep tendon reflexes and palpitations are not associated with metabolic acidosis.)

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The clients arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3 18 mEq/L. Which manifestation should the nurse identify as an example of the clients compensation mechanism? A. Increased rate and depth of respirations B. Increased urinary output C. Increased thirst and hunger D. Increased release of acids from the kidneys

A. This client has metabolic acidosis. The respiratory system compensates by increasing its activity and blowing off excess carbon dioxide. Increased urinary output, thirst, and hunger are manifestations of hyperglycemia but are not compensatory mechanisms for acid-base imbalances. The kidneys do not release acids

The nurse is preparing to admit a client with acute pneumonia who is experiencing severe respiratory acidosis. The nurse anticipates that treatment for this client may include which actions?Select all that apply. A) Administer oxygen prn. B) Administer digoxin for heart failure. C) Encourage up to 3L of fluids per day. D) Place in a prone position. E) Reposition frequently.

ACE The client with acute pneumonia and respiratory acidosis may require oxygen administration to improve gas exchange, increased fluid intake to thin secretions, and frequent repositioning to preventing the pooling of respiratory sections. There is not enough evidence to know whether the client is experiencing heart failure as a result of the acute pneumonia.

A company driver is found at the scene of an automobile accident in a state of emotional distress. He tells the paramedics that he feels dizzy, tingling in his fingertips, and does not remember what happened to his car. Respiratory rate is rapid at 34/minute. Which primary acid-base disturbance is the young man at risk for if medical attention is not provided? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

B

A nurse is caring for a 65 year old with pneumonia. The arterial blood gases come back as pH 7.25, PaCO2 52 mmHg, HCO3 24 mEq/L, and PaO2 66 mmHg. The nurse interprets these blood gases as: A.Respiratory alkalosis B.Respiratory acidosis C.Metabolic alkalosis D.Metabolic acidosis

B

A patient who is hospitalized due to vomiting and a decreased level of consciousness displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. The doctor diagnosed him of having dehydration. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 22 mm Hg, and HCO3 14 mmol/L; other results are Na+ 120 mmol/L, K+ 2.5 mmol/L, and Cl- 95 mmol/L. As a knowledgeable nurse, you know that the normal value for PaCO2 is: A. 22 mm Hg B. 36 mm Hg C. 48 mm Hg D. 50 mm Hg

B

An elderly client was admitted to hospital in a coma. Analysis of the arterial blood gave the following values: PCO2 16 mm Hg, HCO3- 5 mmol/L and pH 7.1. As a well-rounded nurse, you know that the normal value for HCO3 is: A. 20 mmol/L B. 24 mmol/L C. 29 mmol/L D. 31 mmol/L

B

Comes from bone, joint, muscle, skin or connective tissue; is usually aching or throbbing in quality & well localized: A. Nociceptive pain B. Somatic pain C. Visceral pain D. Neuropathic pain

B

George Kent is a 54-year-old widower with a history of chronic obstructive pulmonary disease and was rushed to the emergency department with increasing shortness of breath, pyrexia, and a productive cough with yellow-green sputum. He has difficulty communicating because of his inability to complete a sentence. One of his sons, Jacob, says he has been unwell for three days. Upon examination, crackles and wheezes can be heard in the lower lobes; he has tachycardia and a bounding pulse. Measurement of arterial blood gas shows pH 7.3, PaCO2 68 mm Hg, HCO3 28 mmol/L, and PaO2 60 mm Hg. How would you interpret this? A. Respiratory Acidosis, Uncompensated B. Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Acidosis, Partially Compensated

B

Mr. Wales, who underwent post-abdominal surgery, has a nasogastric tube. The nurse on duty notes that the nasogastric tube (NGT) is draining a large amount (900 cc in 2 hours) of coffee ground secretions. The client is not oriented to person, place, or time. The nurse contacts the attending physician and STAT ABGs are ordered. The results from the ABGs show pH 7.57, PaCO2 37 mmHg and HCO3 30 mEq/L. What is your assessment? A. Metabolic Acidosis, Uncompensated B. Metabolic Alkalosis, Uncompensated C. Respiratory Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated

B

Mrs. Johansson, who had undergone surgery in the post-anesthesia care unit (PACU), is difficult to arouse two hours following surgery. Nurse Florence in the PACU has been administering Morphine Sulfate intravenously to the client for complaints of post-surgical pain. The client's respiratory rate is 7 per minute and demonstrates shallow breathing. The patient does not respond to any stimuli. The nurse assesses the ABCs (remember Airway, Breathing, Circulation!) and obtains ABGs STAT! Measurement of arterial blood gas shows pH 7.10, PaCO2 70 mm Hg, and HCO3 24 mEq/L. What does this mean? A. Respiratory Alkalosis, Partially Compensated B. Respiratory Acidosis, Uncompensated C. Metabolic Alkalosis, Partially Compensated D. Metabolic Acidosis, Uncompensated

B

The nurse has admitted a client who was brought to the hospital after a morphine overdose. What acid-base imbalance does the nurse expect to observe in this client? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis

B

The nurse has applied a hypothermia blanket to a client with a fever. A priority for the nurse is to inspect the skin frequently to detect which complication of hypothermia blanket use? A. Frostbite B. Skin breakdown C. Venous insufficiency D. Arterial insufficiency

B

The patient rates his pain as a 6 on a scale of 0 to 10, with 0 being no pain and 10 being the worst pain. The patient's wife says that he can't be in that much pain since he has been sleeping for 30 minutes. Which is the most accurate resource for assessing the pain? A. The patient's wife is the best resource for determining the level of pain since she has been with him continually for the entire day. B. The patient's report of pain is the best method for assessing the pain. C. The patient's health care provider has the best knowledge of the level of pain that the patient that should be experiencing. D. The nurse is the most experienced at assessing pain.

B

Three-year-old Adrian is admitted to the hospital with a diagnosis of asthma and respiratory distress syndrome. The mother of the child reports to the nurse on duty that she has witnessed slight tremors and behavioral changes in her child over the past four days. The attending physician orders routine ABGs following an assessment of the ABCs. The ABG results are pH 7.35, PaCO2 72 mmHg, and HCO3 38 mEq/L. What acid-base disorder is shown? A. Respiratory Acidosis, Uncompensated B. Respiratory Acidosis, Fully Compensated C. Respiratory Alkalosis, Fully Compensated D. Metabolic Alkalosis, Partially Compensated

B

To assess a patient's quality of pain the nurse asks which question? A. On a scale of 1-10, how would you rate your pain? B. What word best describes the pain you are experiencing? C. What actions do you take to relieve pain? D. What do you fear most about your pain?

B

Which of the following instructions for use of a patient-controlled analgesia (PCA) pump is most important when educating the patient and family before implementation? A. Notify the nurse when you need to push the button on the pump. B. Only the patient should push the button for more medication. C. A spouse can push the button when the patient is asleep. D. Wait for the pain to become at least a 7 on the pain scale before pushing the button.

B

pH 7.64, PaCÓ 25, HCǑ- 19 A. Respiratory Acidosis, Uncompensated B. Respiratory Alkalosis, Partially Compensated C. Respiratory Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated

B

which patient outcome best reflects adequate management for pain originally rated as 8 out of 10 on a pain scale? A. The patient is observed quietly watching television B. The patient rates current pain as 4 out of 10 C. The patient tells NAP that he is not hurting as much D. The patient is observed sleeping, with a respiration rate of 20 breaths per minute

B

The client tells the nurse that he ingests large amounts of oral antacids on a daily basis. The nurse plans care knowing that the excessive use of oral antacids containing bicarbonate can result in which acid-base disturbance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Increases in base components occur as a result of oral or parenteral intake of bicarbonates, carbonates, acetates, citrates, or lactates. Excessive use of oral antacids containing bicarbonate can cause a metabolic alkalosis. The remaining acid-base disturbances are incorrect.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis is defined as a deficit or loss of hydrogen ions or acids or an excess of base (bicarbonate) that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions resulting in hypovolemia, the loss of gastric fluid, excessive bicarbonate intake, the massive transfusion of whole blood, and hyperaldosteronism. Loss of gastric fluid via nasogastric suction or vomiting causes metabolic alkalosis as a result of the loss of hydrochloric acid. The remaining options are incorrect interpretations.

A nurse evaluates the following arterial blood gas values in a client: pH 7.48, PaO2 98 mm Hg, PaCO2 28 mm Hg, and HCO3 22 mEq/L. Which client condition should the nurse correlate with these results? A. Diarrhea and vomiting for 36 hours B. Anxiety-induced hyperventilation C. Chronic obstructive pulmonary disease (COPD) D. Diabetic ketoacidosis and emphysema

B. The elevated pH level indicates alkalosis. The bicarbonate level is normal, and so is the oxygen partial pressure. Loss of carbon dioxide is the cause of the alkalosis, which would occur in response to hyperventilation. Diarrhea and vomiting would cause metabolic alterations, COPD would lead to respiratory acidosis, and the client with emphysema most likely would have combined metabolic acidosis on top of a mild, chronic respiratory acidosis.

A client with severe metabolic alkalosis has been admitted to the unit and is being cared for by a nursing student along with the nurse. What should the nurse say is a priority for this client? A) Administering medication for metabolic alkalosis B) Monitoring oxygen saturation C) Teaching the client the risk factors for metabolic alkalosis D) Setting goals for the client with metabolic alkalosis

B. The priority for this client is monitoring oxygen saturation. The depressed respiratory drive that often accompanies metabolic alkalosis can lead to hypoxemia and impaired oxygenation of the tissues. Administering medications will be needed as a treatment, but the priority is to discover the cause. Teaching the client and setting goals are important aspects of nursing care but are not the priority.)

A client has a history of severe chronic pain. Which is the most important intervention associated with providing nursing care to this client? A. Asking what is an acceptable level of pain B. Providing interventions that do not precipitate pain C. Focusing on pain management intervention before pain is excessive D. Determining the level to function that can be preformed without pain

C

A nurse is caring for a client with a nasogastric tube requiring low intermittent suction. The arterial blood gases come back as pH 7.48 , PaCO2 44 mmHg, HCO3 28 mEq/L, and PaO2 90 mmHg. The nurse interprets these blood gases as: A.Respiratory alkalosis B.Respiratory acidosis C.Metabolic alkalosis D.Metabolic acidosis

C

A nurse is working with a patient who has a contagious condition. In recalling the chain of infection, the nurse knows that an environment favorable for the growth and reproduction of an infectious agent is referred to as ____. A. vector B. a susceptible host C. a reservoir D. a portal of entry

C

A patient with a history of stroke 4 years ago resulting in aphasia (inability to verbally express thoughts) returns to the surgical unit after a cholecystectomy. The surgeon ordered an intravenous pain medication every 4 hours as needed (PRN) for postoperative pain. The best nursing intervention related to pain control after surgery would be to: A. Administer the pain medication when the patient becomes restless B. Wait until the patient verbalizes that he is experiencing pain to administer the pain medication. C. Assess the patient's level of pain using a Faces Pain Scale and administer pain medication as ordered D. Administer the pain medication every 4 hours as the client can't express pain.

C

An old beggar was admitted to the emergency department due to shortness of breath, fever, and a productive cough. Upon examination, crackles and wheezes are noted in the lower lobes; he appears to be tachycardic and has a bounding pulse. Measurement of arterial blood gas shows pH 7.2, PaCO2 66 mm Hg, HCO3 27 mmol/L, and PaO2 65 mm Hg. As a knowledgeable nurse, you know that the normal value for pH is: A. 7.20 B. 7.30 C. 7.40 D. 7.50

C

Anne, who is drinking beer at a party, falls and hits her head on the ground. Her friend Liza dials "911" because Anne is unconscious, depressed ventilation (shallow and slow respirations), rapid heart rate, and is profusely bleeding from both ears. Which primary acid-base imbalance is Anne at risk for if medical attention is not provided? A. Metabolic Acidosis B. Metabolic Alkalosis C. Respiratory Acidosis D. Respiratory Alkalosis

C

Arises from organs such as the gastrointestinal tract & pancreas; is sometimes subdivided: A. Nociceptive pain B. Somatic pain C. Visceral pain D. Neuropathic pain

C

Baby Angela was rushed to the Emergency Room following her mother's complaint that the infant has been irritable, difficult to breastfeed, and has had diarrhea for the past 3 days. The infant's respiratory rate is elevated and the fontanels are sunken. The Emergency Room physician orders ABGs after assessing the ABCs. The results from the ABG results show pH 7.39, PaCO2 27 mmHg, and HCO3 19 mEq/L. What does this mean? A. Respiratory Alkalosis, Fully Compensated B. Metabolic Acidosis, Uncompensated C. Metabolic Acidosis, Fully Compensated D. Respiratory Acidosis, Uncompensated

C

Following surgery, a client has great difficulty getting out of bed, walking, and coughing and deep breathing. Although patient-controlled analgesia (PCA) is in place, it is rarely used, even when suggested by the nurse. This concerns the nurse. Which statement is the best way to address this concern with the client? A. "I noticed you use very little pain medication. You must be very brave and strong. But without pain medication, you will get weaker, not stronger." B. "I noticed you don't use much pain medication. If you don't push that button, I will. You need that medicine. Don't worry about getting addicted. It won't happen." C. "I noticed you haven't used your pain medication as often as you could, even though it is painful for you to get out of bed and to walk. Many people are reluctant to take pain medication. Tell me what makes you reluctant." D. "I can understand why you are reluctant to use pain medication. Many people feel the same way. Yet without pain relief, you can get atelectasis, pneumonia, and blood clots, and maybe even develop an ileus."

C

Liza's mother is seen in the emergency department at a community hospital. She admits that her mother is taking many tablets of aspirin (salicylates) over the last 24-hour period because of a severe headache. Also, the mother complains of an inability to urinate. The nurse on duty took her vital signs and noted the following: Temp = 97.8 °F; apical pulse = 95; respiration = 32 and deep. Which primary acid-base imbalance is the client at risk for if medical attention is not provided? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

C

Pt admitted with an acid-base imbalance. ABG results are pH 7.33; PaCO2 49; HCO3 28. How would the nurse interpret these results? A. Uncompensated respiratory acidosis B. Metabolic alkalosis, uncompensated C. Partially compensated respiratory acidosis D. Partially compensated metabolic acidosis

C

Pt's ABG results are pH 7.48; PaCO2 30; HCO3 23. How will the nurse interpret these results? A. Compensated respiratory alkalosis B. Uncompensated metabolic alkalosis C. Uncompensated respiratory alkalosis D. Compensated metabolic alkalosis

C

Ricky's grandmother has been suffering from persistent vomiting for two days now. She appears to be lethargic and weak and has myalgia. She is noted to have dry mucus membranes and her capillary refill takes >4 seconds. She is diagnosed as having gastroenteritis and dehydration. Measurement of arterial blood gas shows pH 7.5, PaO2 85 mm Hg, PaCO2 40 mm Hg, and HCO3 34 mmol/L. What acid-base disorder is shown? A. Respiratory Alkalosis, Uncompensated B. Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated

C

The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? A. Radiation B. Convection C. Conduction D. Evaporation

C

The nurse is evaluating the statements made by the nursing student about pain. Which statement made by the nursing student is true? A. "Psychogenic pain is not real" B. " Drug abusers overreact to the pain" C. "Intensity of the pain does not accurately indicate the tissue damage" D. "Patients with minor illness have less pain than patients with major trauma"

C

The nurse is planning care for an older client with respiratory acidosis. Which intervention should the nurse include in this client's plan of care? A) Administer prescribed intravenous fluids carefully. B) Administer intravenous sodium bicarbonate. C) Maintain adequate hydration. D) Reduce environmental stimuli.

C

To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? A. Chest x-ray B. Oxygen saturation C. Arterial blood gas analysis D. Central venous pressure monitoring

C

When the nurse is assessing a client, the client states, "The pain moves from my chest down my left arm" Which characteristics of pain is associated with this statement? A. Pattern B. Duration C. Location D. Constancy

C

Which is most important for nurses to understand when caring for clients in pain? A. Clients who are in pain will request pain medication B. Clients usually are able to describe the characteristics of their pain C. Clients need to know that the nurse believes what they say about their pain D. Clients will demonstrate vital signs that are more congruent with the intensity of their pain

C

pH 7.4, PaCÓ 59, HCǑ- 35 A. Respiratory Acidosis, Uncompensated B. Metabolic Alkalosis, Uncompensated C. Respiratory Acidosis, Fully Compensated D. Metabolic Alkalosis, Partially Compensated

C

what is the nurses primary goal for appropriate, effective pain management when considering the patient's risk for injury? A. To minimize the potential for analgesic induced dependency B. to evaluate the effect of pain on the patient's ability to provide self-care C. to maximize pain relief while maintaining the patient's ability to function D. to identify the patients need for both physical and emotional pain relief

C

when a patient is using PCA, which statement is appropriate for the nurse to make to the NAP? A. "Let me know if the patient has any problems using the PCA pump" B. "Let me know when the patient's vital signs indicate that he has pain" C. "Tell me if the patient is in too much pain to assist with his bath" D. " The patient is confused and will need your help operating the PCA pump"

C

The client has been vomiting for several days. The nurse knows that the client is at risk for metabolic alkalosis because gastric secretions have which of the following characteristics? A) Gastric secretions are green in color. B) Gastric secretions are alkaline. C) Gastric secretions are acidic. D) Gastric secretions have a foul smell.

C ( Metabolic alkalosis due to loss of hydrogen ions usually occurs because of vomiting or gastric suction. Gastric secretions are highly acidic (pH 1-3). When these are lost through vomiting or gastric suction, the alkalinity of body fluids increases. This increased alkalinity results from the loss of acid and from selective retention of bicarbonate by the kidneys as chloride is depleted. Gastric secretions are now alkaline. The color and odor of gastric secretions have no influence on the development of metabolic acidosis.)

A male client is admitted with a history of diabetes and diarrhea. His respiratory rate is elevated as a compensatory mechanism. What acid-base balance should the nurse expect? A. Metabolic alkalosis B. Respiratory alkalosis C. Metabolic acidosis D. Respiratory acidosis

C Diabetes and diarrhea put the client at risk for metabolic acidosis and the increase in respiratory rate is the compensatory mechanism for the body to attempt to get rid of the acid.

Your patient is hyperventilating from acute pain and hypoxia. Interventions to manage his pain and oxygenation will decrease his risk of which acid-base imbalance? A. Metabolic acidosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic alkalosis

C Hyperventilation causes excessive excretion of carbonic acid, putting the patient at risk for developing respiratory alkalosis. Interventions to decrease the pain and hypoxia that are causing his hyperventilation will decrease his risk of respiratory alkalosis

A patient seeks care for "debilitating headaches that cause excessive absences at work." On further exploration, the nurse asks, "What makes the headaches worse?" With this question, the nurse is seeking information about: A. the patient's perception of pain. B. the nature or character of the headache. C. aggravating factors. D. relieving factors.

C. Aggravating factors are determined by asking the patient what makes the pain worse.To determine the patient's perception of pain, the nurse would determine the meaning of the symptom by asking how it affects daily activities and what the patient thinks the pain means.The nature or character calls for specific descriptive terms to describe the pain.Relieving factors are determined by asking the patient what relieves the pain, what is the effect of any treatment, what the patient has tried, and what seems to help.

After providing discharge teaching, a nurse assesses the clients understanding regarding increased risk for metabolic alkalosis. Which statement indicates the client needs additional teaching? A. I dont drink milk because it gives me gas and diarrhea. B. I have been taking digoxin every day for the last 15 years. C. I take sodium bicarbonate after every meal to prevent heartburn. D. In hot weather, I sweat so much that I drink six glasses of water each day.

C. Excessive oral ingestion of sodium bicarbonate and other bicarbonate-based antacids can cause metabolic alkalosis. Avoiding milk, taking digoxin, and sweating would not lead to increased risk of metabolic alkalosis.

A client with history of chronic alcoholism and malnutrition has a pH of 7.30 and an HCO3 of 20. The nurse should also expect to see which laboratory value and symptom manifestation?A. Serum Calcium level of 6.2 mEq/L and muscle weakness. B. Serum Magnesium level of 2.8 mcg/L and hypotension. C. Serum Potassium level of 6.0 mEq/L and flaccid paralysis. D. Serum Sodium level of 130 mEq/L and tachycardia.

C. Hyperkalemia is frequently associated with metabolic acidosis. In acidosis, the kidney must excrete more hydrogen ions, which means less secretion of potassium ions. An abundance of hydrogen ions in the bloodstream means that some of the ions go into the cells, driving potassium out of the cells. Therefore, in metabolic acidosis, the total body potassium is not increased, but more potassium ions are in the bloodstream. Since potassium is important to muscle contraction as the level builds in the bloodstream

A 45-year-old patient who reports pain in the foot that moves up along the calf says: "My right foot feels like it is on fire." The patient reports that the pain started yesterday, and he or she has no prior history of injury or falls. Which components of pain assessment has the patient reported? A. Aggravating and alleviating factors. B. Exacerbation, with associated signs and symptoms. C. Intensity, temporal characteristics, and functional impact. D. Location, quality, and onset.

D

A client requests pain medication for severe pain. Which should the nurse do first when responding to this client's requests? A. Use distraction to minimize the client's perception of pain B. Place the client in the most comfortable position possible C. Administer pain medication to the client quickly D. Assess the various aspects of the client's pain

D

A nurse is caring for an 8 year old newly diagnosed type I diabetic. The arterial blood gases come back as pH 7.30, PaCO2 35 mmHg, HCO3 16 mEq/L, and PaO2 92 mmHg. The nurse interprets these blood gases as: A.Respiratory alkalosis B.Respiratory acidosis C.Metabolic alkalosis D.Metabolic acidosis

D

A patient with chronic low back pain who took an opioid around-the-clock (ATC) for the past year decided to abruptly stop the medication for fear of addiction. He is now experiencing shaking chills, abdominal cramps, and joint pain. The nurse recognizes that this patient is experiencing symptoms of: A. Addiction. B. Tolerance. C. Pseudoaddiction. D. Physical dependence.

D

Both clients and nurses have misconceptions about pain. Which statement reflects a misconception? A. People can adapt to severe pain. B. Minor injuries can cause intense pain. C. The client is the authority about pain. D. Regular administration of analgesics leads to addiction.

D

Carl, an elementary student, was rushed to the hospital due to vomiting and a decreased level of consciousness. The patient displays slow and deep (Kussmaul breathing), and he is lethargic and irritable in response to stimulation. He appears to be dehydrated—his eyes are sunken and mucous membranes are dry—and he has a two-week history of polydipsia, polyuria, and weight loss. Measurement of arterial blood gas shows pH 7.0, PaO2 90 mm Hg, PaCO2 23 mm Hg, and HCO3 12 mmol/L; other results are Na+ 126 mmol/L, K+ 5 mmol/L, and Cl- 95 mmol/L. What is your assessment? A. Respiratory Acidosis, Uncompensated B. Respiratory Acidosis, Partially Compensated C. Metabolic Alkalosis, Uncompensated D. Metabolic Acidosis, Partially, Compensated

D

In a patient undergoing surgery, it was vital to aspirate the contents of the upper gastrointestinal tract. After the operation, the following values were acquired from an arterial blood sample: pH 7.55, PCO2 52 mm Hg and HCO3- 40 mmol/l. What is the underlying disorder? A. Respiratory Acidosis B. Respiratory Alkalosis C. Metabolic Acidosis D. Metabolic Alkalosis

D

When asked about pain, a client complains of having severe discomfort from arthritis. Vital signs are unchanged, and the client is calmly watching television. Which of the following nursing diagnoses is most appropriate? A. Acute pain B. Altered sensory perception C. Impaired mobility D. Chronic pain

D

pH 7.17, PaCÓ 48, HCǑ- 36 A. Respiratory Acidosis, Uncompensated B. Metabolic Acidosis, Partially Compensated C. Respiratory Alkalosis, Partially Compensated D. Respiratory Acidosis, Partially Compensated

D

pH 7.5, PaCÓ 19, HCǑ- 22 A. Respiratory Alkalosis, Partially Compensated B. Metabolic Alkalosis, Partially Compensated C. Respiratory Acidosis, Uncompensated D. Respiratory Alkalosis, Uncompensated

D

A nurse is caring for a client who is experiencing moderate metabolic alkalosis. Which action should the nurse take? A. Monitor daily hemoglobin and hematocrit values. B. Administer furosemide (Lasix) intravenously. C. Encourage the client to take deep breaths. D. Teach the client fall prevention measures.

D. The priority nursing care for a client who is experiencing moderate metabolic alkalosis is providing client safety. Clients with metabolic alkalosis have muscle weakness and are at risk for falling. The other nursing interventions are not appropriate for metabolic alkalosis.

A 24-year old patient is admitted to the trauma unit with a diagnosis of a fractured femur after a motor vehicle accident. He states that he has pain in the injured leg. What should be the first action taken by the nurse? A. Administer the lowest dose of pain medication B. Assess the characteristics of the pain C. Call the orthopedic surgeon D. Complete the admission assessment

B

pH 7.34, PaCÓ 24, HCǑ- 20 A. Respiratory Acidosis, Partially Compensated B. Metabolic Acidosis, Partially Compensated C. Metabolic Acidosis, Uncompensated D. Metabolic Alkalosis, Partially Compensated

B

pH 7.55, PaCÓ 25, HCǑ- 22 A. Respiratory Acidosis, Partially Compensated B. Respiratory Alkalosis, Uncompensated C. Metabolic Alkalosis, Partially Compensated D. Metabolic Acidosis, Uncompensated

B

The nurse would assess for which S/S of a pt who has metabolic acidosis? (SELECT ALL THAT APPLY) A. Wt gain B. rapid, deep respirations C. drowsiness D. ↓ respiratory rate and depth E. Melena (dark tarry stools)

BC. Pt with metabolic acidosis develop Kussmaul's breathing (rapid and deep respirations). Drowsiness occurs because of the CNS depressant effect of acidosis

A client's blood gas results reveal acidosis. What are some signs and symptoms the nurse would expect to see? Select all that apply. A. Seizures B. Lethargy C. Headache D. Weakness E. Confusion F. Hyperactivity

BCDE

ABG results are pH 7.50; PaCO2 40; HCO3 29. Which question should the nurse ask the client to help determine an etiology for these results? A. "have you had diarrhea lately? B. "do you have a history of COPD? C. "how long have you had nausea and vomiting?" D. "do you smoke?"

C. ABG results reflect ↑pH (alkalosis), and normal PaCO2, and ↑HCO3 indicating metabolic alkalosis. Vomiting is a common cause of this condition. ** Diarrhea is associate with METABOLIC ACIDOSIS

A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45, which of the following is the most appropriate nursing intervention? A. Administer a sedative B. Place client in left lateral position C. Place client in high-Fowler's position D. Assist the client to breathe into a paper bag

C. This client is in a state of respiratory acidosis. Placing the client in high-Fowler's positions ill facilitate the expansion of the lungs and help the client blow off excess CO2. Sedatives would impede respirations. The question does not indicate which is the affected lung, so left lateral position would not be a first choice. Breathing into a paper bag will cause the PCO2 to rise higher

A nurse is performing an admitting interview. Which client statement about pain should cause the most concern for the nurse? A. "I try to pretend that is is not part of me, but it takes a lot of effort" B. "My pain medication works, but I'm afraid of becoming addicted" C. "At home, I take something for the pain before it gets too bad" D. "They say my pain may get worse, and I can't stand it now"

D

Controlling pain is important to promoting wellness. Unrelieved pain has been associated with which complication? A. Decrease tumor growth and longevity B. Decreased carbohydrate, protein, fat destruction C. Large tidal volumes and decreased lung capacity D. Prolonged stress response and a cascade of harmful effects systemwide

D

To obtain the most complete assessment data about a patient's chronic pain pattern, the nurse asks the patient A. "Can you describe where your pain is the worst?" B. "What is the intensity of your pain on a scale of 0 to 10?" C. "Would you describe your pain as aching, throbbing, or sharp?" D. "Can you describe your daily activities in relation to your pain?"

D. The assessment of chronic pain should focus on the impact of the pain on patient function and daily activities. The other questions are also appropriate to ask, but will not give as complete information.

What two organs in the body serve as a compensatory function to maintain acid base balance? A. Kidneys and Lungs B. Lungs and Spleen C. Heart and Liver D. Gallbladder and Appendix

A