NCLEX Study Questions
A) 7.20 The pH of blood is maintained within the narrow range of 7.35 to 7.45. When there is an increase in hydrogen ions, the respiratory, buffer, and renal systems attempt to compensate to maintain the pH. If compensation is not successful, acidosis results and is reflected in a lower pH.
A client is in a state of uncompensated acidosis. What approximate arterial blood pH does the nurse expect the client to have? A) 7.20 B) 7.35 C) 7.45 D) 7.48
A) breathe into cupped hands Breathing into cupped hands allows carbon dioxide to reenter the lungs, which will increase the serum bicarbonate level, relieving the respiratory alkalosis that is occurring as a result of hyperventilation. A rapid breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A fast deep-breathing pattern will exacerbate the respiratory alkalosis because excess carbon dioxide will continue to be expelled with rapid breathing, lowering the serum bicarbonate level. A person who is experiencing a panic attack will not be able to hold his or her breath.
An 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do? A) Breathe into cupped hands. B) Pant using rapid, shallow breaths. C) Use a rapid deep-breathing pattern. D) Hold the breath for as long as possible
D) Increased digitalis toxicity Increased digitalis toxicity is one of the cardiovascular manifestations of alkalosis. Anxiety and seizures are central nervous system manifestations of alkalosis. Hyperreflexia is a neuromuscular manifestation of alkalosis.
Which would the nurse claim is a cardiovascular manifestation of alkalosis? A) Anxiety B) Seizures C) Hyperreflexia D) Increased digitalis toxicity
A) Sodium and chloride levels Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.
A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? A) Sodium and chloride levels B) Bicarbonate and sulfate levels C) Magnesium and protein levels D) Calcium and phosphate levels
C) Metabolic alkalosis The normal plasma pH value is 7.35 to 7.45; the client is in alkalosis. The normal plasma bicarbonate value is 23 to 25 mEq/L (23 to 25 mmol/L); the client has an excess of base bicarbonate, indicating a metabolic cause for the alkalosis. The normal plasma sodium value is 135 to 145 mEq/L (135 to 145 mmol/L); the client has hyponatremia. The normal plasma chloride value is 95 to 105 mEq/L (95 to 105 mmol/L); the client has hypochloremia because of vomiting of gastric secretions. With respiratory acidosis the pH is decreased to less than 7.35.
A client is hospitalized after four days of epigastric pain, nausea, and vomiting. The nurse reviews the laboratory test results: plasma pH 7.51, Pco 2 50 mm Hg, bicarbonate 58 mEq/L (58 mmol/L), chloride 55 mEq/L (55 mmol/L), sodium 132 mEq/L (132 mmol/L), and potassium 3.8 mEq/L (3.8 mmol/L). What condition does the nurse determine the results to indicate? A) Hypernatremia B) Hyperchloremia C) Metabolic alkalosis D) Respiratory acidosis
A) Respiratory acidosis The pH indicates acidosis, the PCO 2 level is the parameter for respiratory function. The expected PCO 2 is 40 mm Hg. These results do not indicate a metabolic disorder or indicate respiratory alkalosis.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a PCO 2 of 60 mm Hg. What complication does the nurse conclude the client is experiencing? A) Respiratory acidosis B) Metabolic acidosis C) Metabolic alkalosis D) Respiratory Acidosis
A) Nasogastric tube for decompression Decompression removes collected secretions behind the nonfunctioning bowel segment (paralytic ileus), thus reducing pressure on the suture line and allowing healing. Vomiting will subside as the bowel is decompressed. Although IV lactated Ringer for fluid replacement is important, the primary concern is decompression of the bowel; the amount of fluid removed will direct fluid and electrolyte replacement therapy.
A client with colitis has had a hemicolectomy. Three days after surgery the nurse identifies that the client has abdominal distention and absent bowel sounds, and has vomited 300 mL of dark green viscous fluid. The nurse contacts the primary healthcare provider and recommends which intervention? A) Nasogastric tube for decompression B) Antiemetic for nausea/vomiting C) Intravenous (IV) lactated Ringer for fluid replacement D) Stat electrolytes to assess for probable electrolyte imbalance
B) Carbonic acid deficit Hyperventilation causes excessive loss of carbon dioxide, leading to carbonic acid deficit and respiratory alkalosis. Cardiac arrest is unlikely; the client may experience dysrhythmias but will lose consciousness and begin breathing regularly. Hyperventilation causes alkalosis; the pH is increased. Excess oxygen saturation cannot occur; the usual oxygen saturation of hemoglobin is 95% to 98%.
A nurse addresses the needs of a client who is hyperventilating to prevent what complication? A) Cardiac arrest B) Carbonic acid deficit C) Reduction in serum pH D) Excess oxygen saturation
C) Rapid absorption of salicylate Rapid absorption of acetylsalicylic acid (aspirin) causes the stomach contents to become more acidic, leading to metabolic acidosis. Hyperventilation is the body's attempt to blow off excess hydrogen ions; carbon dioxide is converted to hydrogen ions by way of the carbonic anhydrase reaction. The pH of the stomach contents decreases with aspirin toxicity, becoming more acidic, resulting in metabolic acidosis. Although increased renal excretion of bicarbonate can contribute to metabolic acidosis, this is not the mechanism associated with aspirin toxicity. In metabolic acidosis associated with aspirin toxicity the kidneys attempt to decrease the renal excretion of bicarbonate.
A nurse is admitting a 2-year-old toddler who ingested half of a bottle of aspirin tablets to the emergency department. What is the origin of the metabolic acidosis caused by aspirin toxicity? A) Deep rapid breathing B) Higher pH of gastric contents C) Rapid absorption of salicylate D) Increased renal excretion of bicarbonate
A) Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate Bicarbonate buffering is limited, hydrogen ions accumulate, and acidosis results. The rate of respirations increases in metabolic acidosis to compensate for a low pH. The fluid balance does not significantly alter the pH. The retention of sodium ions is related to fluid retention and edema rather than to acidosis.
A nurse is assessing a client with a diagnosis of kidney failure for clinical indicators of metabolic acidosis. What should the nurse conclude is the reason metabolic acidosis develops with kidney failure? A) Inability of the renal tubules to secrete hydrogen ions and conserve bicarbonate B) Depressed respiratory rate due to metabolic wastes, causing carbon dioxide retention C) Inability of the renal tubules to reabsorb water to dilute the acid contents of blood D) Impaired glomerular filtration, causing retention of sodium and metabolic waste products
C) Respiratory acidosis Shallow respirations, bronchial tree obstruction, and atelectasis compromise gas exchange in the lungs; an increased carbon dioxide level leads to respiratory acidosis [1] [2]. Metabolic acidosis occurs with diarrhea; alkaline fluid is lost from the lower gastrointestinal tract. Metabolic alkalosis is caused by excessive loss of hydrogen ions through gastric decompression or excessive vomiting. Respiratory alkalosis is caused by increased expiration of carbon dioxide, a component of carbonic acid.
A nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent? A) Metabolic acidosis B) Metabolic alkalosis C) Respiratory acidosis D) Respiratory alkalosis
A) pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) A client in diabetic ketoacidosis will have blood gas readings that indicate metabolic acidosis. The pH will be acidic (7.30), and the HCO 3 - will be low (20 mEq/L [20 mmol/L]). The normal pH is 7.35 to 7.45; CO 2 ranges from 35 to 45 mm Hg, and HCO 3 - ranges from 22 to 26 (22 to 26 mmol/L). A pH of 7.35 and a CO 2 of 47 mm Hg indicate respiratory acidosis. pH values of 7.46 and 7.50 represent alkalosis, not acidosis.
Which blood gas result should the nurse expect an adolescent with diabetic ketoacidosis to exhibit? A) pH 7.30, CO 2 40 mm Hg, HCO 3 - 20 mEq/L (20 mmol/L) B) pH 7.35, CO 2 47 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) C) pH 7.46, CO 2 30 mm Hg, HCO 3 - 24 mEq/L (24 mmol/L) D) pH 7.50, CO 2 50 mm Hg, HCO 3 - 22 mEq/L (22 mmol/L
C) Insulin aspart Insulin aspart is a rapid-acting insulin (within 10 to 20 minutes) and is used to meet a client's immediate insulin needs. Glargine is a long-acting insulin, which has an onset of 1.5 hours; for diabetic acidosis, the individual needs rapid-acting insulin. NPH insulin is an intermediate-acting insulin, which has an onset of 1 to 2 hours; for diabetic acidosis, the individual needs rapid-acting insulin. Insulin detemir is a long-acting insulin; for diabetic acidosis, the individual needs rapid-acting insulin.
Which insulin should the nurse prepare for the emergency treatment of ketoacidosis? A) Glargine B) NPH insulin C) Insulin aspart D) Insulin detemir
A) Monitoring for signs of hypoglycemia resulting from treatment During treatment for acidosis, hypoglycemia may develop; careful observation for this complication should be made by the nurse. Withholding all glucose may cause insulin coma. Whole milk and fruit juices are high in carbohydrates, which are contraindicated immediately following ketoacidosis. The regulation of insulin depends on the prescription for coverage; the prescription usually depends on the client's blood glucose level rather than ketones in the urine
Which is an independent nursing action that should be included in the plan of care for a client after an episode of ketoacidosis? A) Monitoring for signs of hypoglycemia resulting from treatment B) Withholding glucose in any form until the situation is corrected C) Giving fruit juices, broth, and milk as soon as the client is able to take fluids orally D) Regulating insulin dosage according to the amount of ketones found in the client's urine
B) Metabolic Acidosis Prolonged use of sodium bicarbonate may cause systemic alkalosis, as well as retention of sodium and water
A nurse teaches a client about the dangers of using bicarbonate of soda regularly. What effect of bicarbonate of soda is the nurse trying to prevent? A) Gastric Distention B) Metabolic Acidosis C) Chronic Constipation D) Cardiac Dysrhythmias
B) Liver Uric acid stones are controlled by a low-purine diet. Foods high in purine, such as organ meats and extracts, should be avoided. Milk should be avoided with calcium, not uric acid, stones. Cheese or animal protein should be avoided with cystine, not uric acid, stones. Vegetables do not have to be avoided.
A pathology report states that a client's urinary calculus is composed of uric acid. Which food item should the nurse instruct the client to avoid? A) Milk B) Liver C) Cheese D) Vegetables
D) Assessing the IV site for infiltration Assessment of the IV site is a priority. The infant will need IV fluids until oral feedings are possible. Restraints are not needed. Administering a sedative is not necessary and should not be done until a full assessment is completed. If the infant has a nasogastric tube in place, it should not be removed until an assessment of bowel sounds and nausea and vomiting is done.
Corrective surgery for hypertrophic pyloric stenosis is completed, and the infant is returned to the pediatric unit with an intravenous (IV) infusion in progress. What is the priority nursing action? A) Applying adequate restraints B) Administering a mild sedative C) Removing the nasogastric tube D) Assessing the IV site for infiltration
B) It decreases production of thyroid hormones. Propylthiouracil is a thyroid hormone antagonist that inhibits thyroid hormone synthesis by decreasing the use of iodine in the manufacture of these hormones. PTU does not affect the vascularity of the thyroid gland. Iodine-containing agents are given for severe hyperthyroidism and before a thyroidectomy. PTU does not affect the amount of already formed thyroid hormones
Propylthiouracil is prescribed for a client diagnosed with hyperthyroidism. The client asks the nurse, "Why do I have to take this medication if I am going to get radiation therapy?" What explanation does the nurse provide? A) It binds previously formed thyroid hormones. B) It decreases production of thyroid hormones. C) Vascularity of the thyroid gland is decreased. D) The need for thyroid iodine supplements is reduced.
C) Regular formula feeding within 24 hours of the surgery An initial feeding of glucose and electrolytes in water or breast milk is given 4 to 6 hours after surgery. Once clear fluids are being retained, formula feedings are begun within 24 hours. Thickened formula 24 hours after surgery is not necessary. Regular formula should be started within 24 hours after surgery in an attempt to gradually return the infant to a full feeding schedule. Withholding feedings for the first 24 hours and providing additional glucose feedings as desired after the first 24 hours are not necessary.
Surgery to correct hypertrophic pyloric stenosis is performed on a 3-week-old infant who has been fed formula. Which postoperative feeding regimen is most appropriate? A) Thickened formula 24 hours after surgery B) Withholding of feedings for the first 24 hours C) Regular formula feeding within 24 hours of the surgery D) Additional glucose feedings as desired after the first 24 hours
A) pH: 7.28; PCO 2: 28; HCO 3: 18 A low pH and bicarbonate reflect metabolic acidosis; a low PCO 2 indicates compensatory hyperventilation. A low pH and elevated PCO 2 reflect hypoventilation and respiratory acidosis. An elevated pH and bicarbonate reflect metabolic alkalosis; an elevated PCO 2 indicates compensatory hypoventilation. An elevated pH and low PCO 2 reflect hyperventilation and respiratory alkalosis.
The nurse is caring for a client with a diagnosis of diabetic ketoacidosis. Which arterial blood gas results are associated with this diagnosis? A) pH: 7.28; PCO 2: 28; HCO 3: 18 B) pH: 7.30; PCO 2: 54; HCO 3: 28 C) pH: 7.50; PCO 2: 49; HCO 3: 32 D) pH: 7.52; PCO 2: 26; HCO 3: 20
C) Diminished breath sounds Breath sounds will be decreased in clients with emphysema because of reduced airflow, pleural effusion, or lung parenchymal destruction. A pleural friction rub occurs when one layer of the pleural membrane slides over the other during breathing; this is associated with pleurisy. Crackles indicate fluid in the alveoli, which is associated with heart failure or infection; rhonchi signify airway obstruction, not emphysema. Expiratory wheezing and coughing are associated with asthma or bronchitis.
The nurse is caring for a client with emphysema. During assessment, the nurse expects to auscultate which type of breath sounds? A) Pleural friction rub B) Crackles and gurgles C) Diminished breath sounds D) Expiratory wheeze and cough
D) PCO 2: 28, HCO 3: 18, pH: 7.28 Decreased pH and bicarbonate values reflect metabolic acidosis; a decreased PCO 2 value indicates compensatory hyperventilation. Increased pH and bicarbonate values reflect metabolic alkalosis; an increased PCO 2 value indicates compensatory hypoventilation. Increased pH and decreased PCO 2 values reflect hyperventilation and respiratory alkalosis. Decreased pH and increased PCO 2 values reflect hypoventilation and respiratory acidosis.
The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis? A) PCO 2: 49, HCO 3: 32, pH: 7.50 B) PCO 2: 26, HCO 3: 20, pH: 7.52 C) PCO 2: 54, HCO 3: 28, pH: 7.30 D) PCO 2: 28, HCO 3: 18, pH: 7.28
A) Sodium Sodium is the most abundant extracellular fluid cation and regulates serum (extracellular) osmolarity, as well as nerve impulse transmission and acid-base balance. Potassium is the major intracellular osmolarity regulator, and it also regulates metabolic activities, transmission and conduction of nerve impulses, cardiac conduction, and smooth and skeletal muscle contraction. Chloride is a major extracellular fluid anion and follows sodium. Calcium is an extracellular cation necessary for bone and teeth formation, blood clotting, hormone secretion, cardiac conduction, transmission of nerve impulses, and muscle contraction.
When assessing a client's fluid and electrolyte status, the nurse recalls that the regulator of extracellular osmolarity is what? A) Sodium B) Potassium C) Chloride D) Calcium
B) Tachycardia Tachycardia is a cardiovascular compensatory mechanism as the effort to circulate the decreasing blood volume intensifies. Lethargy is not an initial response to blood loss. The client is more apt to be restless; lethargy may occur later. Breathing may be rapid, not deep, with blood loss. Abdominal pain is not a response to blood loss.
A client is admitted to the emergency department after vomiting bright red blood. After the vomiting ceases and the vital signs are stabilized, the client is transferred to a medical-surgical unit. To assess for bleeding, what should the nurse on the medical-surgical unit should monitor the client for? A) Lethargy B) Tachycardia C) Deep breathing D) Abdominal pain