NUR 120: Fluid, Electrolyte, Acid Base, Respiratory Test

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding?

A. "Do you have any chronic breathing problems?" B. "What is your occupation and what are your hobbies?" C. "How often do you perform aerobic exercise?" D. "Are you taking any medications or herbal supplements?" Ans:A

The nurse is informing a mother on the plan of care for her child, who has just been diagnosed with Influenza. Which statement by the mother indicates correct understanding:

A. "I will need to limit how much liquid she drinks" B. "You will give her medications to treat her symptoms, but an antibiotic will not help" C. "I need to make sure she exercises every day" D. "You will be giving her an antibiotic" Ans:B

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met?

A. 100% of meals being eaten by the client B. The client understanding the need for oxygen C. Intact skin behind the ears D. Unchanged weight for the past 3 days Ans:C

The physician orders 250 ml Zithromax 500mg to infuse over 90 minutes. What would the nurse set the infusion for on the pump?

A. 166.5 ml/hr B. 167.2 ml/hr C. 166.8 ml/hr D. 166.7 ml/hr Ans:D

The physician orders 100 ml of Ampicillin sodium 500 mg to infuse over 20 minutes. What would the nurse set the infusion for on the pump?

A. 30 ml/hr B. 33 ml/hr C. 100 ml/hr D. 300 ml/hr Ans:D

Order: Digoxin 0.5 mg PO once daily Supply: Digoxin 125 mcg tablets How many tablet(s) will the nurse administer?

A. 4 tabs B. 2 tabs C. 3.5 tabs D. 4.5 tabs Ans:A

Order: Infuse 1000ml of D5W with 20 mEq KCL over 18 hours The nurse knows that the pump needs to be set at:

A. 55.6 ml/hr B. 55.7 ml/hr C. 55.4 ml/hr D. 55.5 ml/hr Ans:A

Order: Infuse 350mL of D5W with 40 mEq of NaHCO3 over 6 hours. The nurse knows that the pump needs to be set at:

A. 58.4 ml/hr B. 58.5 ml/hr C. 58.2 ml/hr D. 58.3 ml/hr Ans:D

Which diagnostic tests results provides indication that a client has clinically active TB? Select all that apply

A. A positive Mantoux test with a positive chest x-ray B. A positive Mantoux test with a negative chest x-ray C. A positive chest x-ray D. A positive sputum culture E. A negative Mantoux test Ans:A,C,D

A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration?

A. An 83-year-old with congestive heart failure B. A 55-year-old receiving hypertonic intravenous fluids C. A 36-year-old who is prescribed long-term steroid therapy D. A 76-year-old who is cognitively impaired Ans:D

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action by the nurse is best?

A. Assess for drainage from the site B. Contact the provider and obtain a suture kit C. Cover the insertion site with petroleum jelly dressing D. Reinsert the tube using sterile technique Ans:C

A nurse is assessing a client who has suffered a nasal fracture. Which assessment would the nurse perform first?

A. Bone displacement B. Facial pain C. Airway patency D. Vital signs Ans:C

The nurse understands that the body has 3 main control systems that regulate acid-base balance. Which of the following represents the order of the systems' response?

A. Buffer, Respiratory, Renal B. Renal, Respiratory, Buffer C. Buffer, Renal, Respiratory D. Respiratory, Renal, Buffer Ans:A

The nurse is caring for an elderly client with a 2 year history of bilateral lower paralysis. The client was admitted with a calcium (C+) level of 13.0 mg/dl. Which of the following is most likely the cause?

A. Calcium has moved from the circulatory system to the bone B. Dehydration C. An overdose on calcium supplements D. A lack of mobility and weight-bearing exercise Ans:D

The nurse assesses a young client that reports shortness of breath while jogging or participating in a sports activity. The client denies a sore throat, fever, or productive cough. The nurse expects the client to be diagnosed with which of the following:

A. Chronic Bronchitis B. Pneumonia C. Emphysema D. Asthma Ans:D

The nurse is performing her initial physical assessment on a client with Chronic Obstructive Pulmonary Disease (COPD). Which signs and symptoms should the nurse expect to find? Select all that apply

A. Clubbed fingers and toes B. Decreased respiratory rate C. Barrel chest D. Dyspnea on exertion E. Pink, warm skin Ans:A,C

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority?

A. Educating the client on adherence to the treatment regimen B. Informing the client about follow-up sputum cultures C. Encouraging the client to eat a well-balanced diet D. Teaching the client ways to balance rest with activity Ans:A

The nurse is reviewing a client's lab results and notes a calcium level of 7.9 mg/dl. The nurse might expect which of the following findings when doing the client's assessment?

A. Elevated T-wave on the ECG B. Lethargy C. Deep bone pain D. Positive Chvostek's sign Ans:D

What is the major difference in the patho-physiology of asthma and emphysema?

A. Emphysema is a restrictive airway disease and asthma is an obstructive airway condition. B. Asthma is the result of an inflammatory process and emphysema is a result of inflammatory, infectious, and hyper-responsiveness processes. C. Emphysema results in permanent airflow obstruction and asthma is a reversible restrictive airflow condition D. There is no difference between asthma and emphysema Ans:C

A nurse measures a client's 24-hour fluid intake and documents the findings. To be an accurate indicator of fluid status, what must the nurse also do with the information?

A. Ensure that the information is included in the verbal end-of-shift report. B. Report the exact milliliter of intake to the physician's office nurse. C. Compare the client's intake with the normal range of adult fluid intake. D. Compare the total intake and output of fluids for the 24 hours. Ans:D

Which clinical manifestation in a client with pharyngitis alerts the nurse to the possibility of a bacterial infection?

A. Erythema of the pharynx B. Sore throat C. Hoarseness D. Fever of 102°F Ans:D

A nurse is assessing the respiratory status of the client following a thoracentesis. Which of the following assessment findings would be a priority for the nurse?

A. Few scattered wheezes B. Diminished breath sound on the affected side C. Respiratory rate of 24 breaths/minute D. Equal and bilateral chest expansion Ans:B

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching?

A. Grilled chicken breast with glazed carrots B. Bowl of tomato soup with a grilled cheese sandwich C. Slices of smoked ham with potato salad D. Salami and cheese on whole-wheat crackers Ans:A

A client is diagnosed with right and left lower lobe pneumonia. During auscultation of the lower lung fields, the nurse hears crackles and identifies the client problem of impaired oxygenation. What is the underlying condition associated with the client's condition?

A. Hypocapnia B. Hypoxemia C. Hypercapnia D. Hyperemia Ans:B

The nurse is caring for a client who presented with complaints of diarrhea and muscle cramps. When the client is placed on a cardiac monitor, the nurse notes an elevated T-wave in the client's rhythm. What electrolyte imbalance does the nurse suspect?

A. Hypokalemia B. Hypercalcemia C. Hyperkalemia D. Hypomagnesemia Ans:C

A client is taking a diuretic that increases her urinary output. What would be an appropriate nursing diagnosis on which to base an educational plan?

A. Impaired Urinary Elimination B. Impaired Skin Integrity C. Urinary Retention D. Risk for Deficient Fluid Volume Ans:D

A nurse assesses a client with diabetes mellitus who is admitted with an acid-base imbalance. The client's arterial blood gas values are pH 7.36, PaO2 98 mm Hg, PaCO2 33 mm Hg, and HCO3- 18 mEq/L (18 mmol/L). Which manifestation does the nurse identify as an example of the client's compensation mechanism?

A. Increased release of acids from the kidneys B. Increased rate and depth of respirations C. Increased thirst and hunger D. Increased urinary output Ans:B

The nurse is assessing a 24-year-old client in the ER who reports having just returned to her home to find that she had been robbed. The nurse notes a RR of 32 and a HR of 122. The client is unable to sit still and is crying. The nurse suspects which possible acid/base imbalance? What does the nurse suspect is the cause of this imbalance?

A. Metabolic Acidosis; AMI (Acute Myocardial Infarction) B. Respiratory Acidosis; Hyperventilation C. Respiratory Alkalosis; Hyperventilation D. Metabolic Alkalosis; AMI Ans:C

A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain?

A. Neck circumference B. Average daily fluid intake C. Height and weight D. Occupation and hobbies Ans:D

The unlicensed assistive personnel (UAP) notifies the nurse that the client with emphysema receiving oxygen at 2 L via nasal cannula is short of breath after morning care. What is the nurse's first action?

A. Notify the health care provider immediately. B. Ask the UAP to check the client's SaO2 level. C. Document the incident in the client's chart. D. Instruct the UAP to check vital signs. Ans:B

A client has been diagnosed with airway obstruction during sleep. The nurse will likely include client education about which device for home use?

A. Oxygen via face mask to prevent hypoxia B. Nebulizer treatments with bronchodilators C. Neck brace to support the head and facilitate breathing D. Continuous positive airway pressure (CPAP) to deliver a positive airway pressure Ans:D

The nurse knows that which groups of people are at greatest risk for the development of Tuberculosis (TB) in the United States?

A. People with a strong immune system B. An alcoholic homeless man who is staying in a shelter. C. American-born citizens D. A college student who is living at home. Ans:B

The nurse assesses a client with asthma and finds wheezing throughout all lung fields, along with a decreased oxygen saturation. In addition, the nurse notes suprasternal retractions on inhalation. What is the nurse's best first action?

A. Perform peak expiratory flow readings B. Administer a rescue inhaler (Albuterol) and oxygen C. Assess for a midline trachea D. Call a code Ans:B

Interventions to promote airway clearance include which of the following? Select all that apply

A. Postural Drainage B. Oxygen C. Hydration D. Placing the client in Trendelenburg position E. Effective coughing Ans:A,C.E

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next?

A. Provide the client with ice chips instead of a drink of water. B. Assess the client's gag reflex before giving any food or water. C. Call the physician and request a prescription for food and water. D. Let the client have a small sip to see whether he or she can swallow. Ans:B

A client is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)?

A. Remove the tubing from the client's nose. B. Apply water-soluble ointment to nares and lips. C. Turn the client every 2 hours or as needed. D. Periodically turn the oxygen down or off. Ans:B

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?

A. Report the UAP to the manager. B. Request thicker liquids for meals. C. Assess the client's lung sounds. D. Assign a different UAP to the client. Ans:C

The nurse is caring for an emphysema client. Upon assessment, the nurse finds the following: respiratory rate (RR) of 10, heart rate (HR) of 44, and blood pressure (B/P) of 88/50; pale skin, and altered mental status (AMS). Which acid/base imbalance does the nurse suspect?

A. Respiratory Acidosis B. Metabolic Acidosis C. Respiratory Alkalosis D. Metabolic Alkalosis Ans:A

A client who is found unresponsive has ABG's drawn, with the following results: pH 7.52, PCO2 30 mm Hg, and HCO3 23 mEq/L. The nurse interprets the results as indicating which condition?

A. Respiratory acidosis with compensation B. Respiratory alkalosis without compensation C. Metabolic alkalosis without compensation D. Metabolic acidosis with compensation Ans:B

The nurse reviews the ABG results of a client and notes the following: pH 7.25, PCO2 34 mm Hg, and HCO3 of 19 mEq/L. The nurse analyzes these results as indicating which condition?

A. Respiratory acidosis without compensation B. Metabolic alkalosis without compensation C. Metabolic acidosis with compensation D. Respiratory alkalosis with compensation Ans:C

The nurse is working on the respiratory unit and caring for a client diagnosed with pneumonia. Which information should the nurse include in the plan of care? Select all that apply

A. Restrict the client's smoking to 2 or 3 cigarettes per day B. Plan for periods of rest during activities of daily living (ADL's) C. Monitor the client's pulse oximetry readings every 4 hours D. Place the client on oxygen by nasal cannula E. Place the client on a fluid restriction of 1000ml per day Ans:B,C,D

A nurse cares for a client who is experiencing epistaxis. What action would the nurse take first?

A. Sit the client upright. B. Initiate standard precautions. C. Apply direct pressure. D. Loosely pack the nares with gauze. Ans:B

Which statement is true about the relationship of smoking cessation to the patho-physiology of COPD?

A. Smoking cessation reverses the effects of the airways but not the lungs B. Smoking cessation is an important therapy for asthma but not for COPD C. Smoking cessation completely reverses the damage to the lungs D. Smoking cessation slows the rate of the disease progression Ans:D

A client reporting a "sore throat" also has a temperature of 101.4 °F, a rash, and a positive throat culture. This client will most likely be diagnosed with which type of bacterial infection?

A. Staphylococcus B. Epstein-Barr Virus C. Pneumococcus D. Streptococcus Ans:D

Which procedure has a risk for the complication of pneumothorax?

A. Thoracentesis B. Pulmonary function test (PFT) C. Use of incentive spirometry D. Ventilation-perfusion scan Ans: A

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? Select all that apply.

A. Toxicity B. Explosion C. Absorptive atelectasis D. Dried mucous membranes E. Combustion Ans:A,C,D,E

The nurse is caring for an elderly client with severe viral rhinitis. The nurse should instruct the client that one of the most effective methods of preventing transmission of the organism is to:

A. Use warm salt water gargles B. Wash the hands frequently C. Use cough suppressants D. Take prescribed antibiotics Ans:B

The client is admitted to the nurse's unit with a diagnosis of heart failure. His heart is not pumping effectively, which is resulting in edema and coarse crackles in his lungs. The term for this condition is:

A. atelectasis B. myocardial Infarction C. fluid volume excess D. fluid volume deficit Ans:C

A client has a physician's order for n.p.o (nothing by mouth) following abdominal surgery to repair a bowel obstruction. The client has a nasogastric tube inserted to low intermittent suction. The client requires intravenous therapy for what purpose?

A. replace fluid and electrolytes B. provide protein supplements C. administer blood products D. treat the client's infection Ans:A

The client has acute tonsillitis. What are the primary instructions you should provide to this client?

A. You may gargle with warm salt water as often as you would like B. You should use nasal decongestants to help with the swelling in the tonsils C. Take the antibiotics for the entire time it is prescribed D. Stay at home from work or school until all antibiotics are taken Ans:C