RNSG 1533 HEALTH CARE CONCEPTS II FINAL
QUESTIONS & VERIFIED ANSWERS
1. A nurse is admitting a client who reports flu like symptoms with dysrhythmias
hyperactive reflexes and a new onset of confusion. The nurse should recognize that the
client is experience which of the following conditions? - Answers - Metabolic alkalosis
2. A nurse is caring for a client who has metabolic alkalosis. For which of the following
clinical manifestations should the nurse monitor? (select all that apply.) - Answers -
bicarbonate excess, circumoral paresthesia
3. A nurse is reviewing the medical records of four clients who have an acid base
imbalance. The nurse should recognize that which of the following clients is at risk for
metabolic acidosis? - Answers - Patient who has diarrhea
4. The nurse is reviewing the laboratory values of a client who has respiratory acidosis.
Which of the following findings should the nurse expect? - Answers - PaCO2 50 mm Hg
5. The client is brought to the emergency department after passing out in the local
department store. The client has been fasting and has ketones in the urine. Which acid-
base imbalance will the nurse expect to assess in the client? - Answers - Metabolic
acidosis
6. The patient is hyperventilating from anxiety and abdominal pain. Which assessment
findings should the nurse attribute to respiratory alkalosis? (select all that apply) -
Answers - Tingling in fingertips, Numbness around mouth, Cramping in feet
7. Which statement said by patients indicates that the nurse is teaching regarding
prevention of acid base imbalances is successful? (Select all that apply) - Answers - "I
should take my insulin on time every day," "My aspirin is on a high shelf away from
children," "I have reliable transportation to dialysis sessions"
8. The nurse is analyzing the client's arterial blood gas report, which reveals a pH of
6.58. The client has just suffered a cardiac arrest. Which consequences of this pH value
does the nurse consider for this client? - Answers - Decreased cardiac output
9. The mother of a one month old infant calls the nurse who works in the health clinic.
The mother is concerned because the infant has had vomiting and diarrhea for one day.
The nurse knows that this infant is at risk for metabolic acidosis. Which is the priority
nursing action? - Answers - Instruct the mother to bring the infant to the clinic for
evaluation.
,10. A client with metabolic acidosis has been admitted to the unit from the emergency
department. The client is experiencing confusion and weakness. Which nursing
intervention is a priority for this client? - Answers - Protecting the client from injury
11. The nurse is preparing to teach a client with type 1 diabetes mellitus on the
mechanism behind the development of ketoacidosis. List the order in which the nurse
should provide the information 1. production of lactate and hydrogen ions 2. tissue
hypoxemia 3. breakdown of fatty tissue 4. reduction and intracellular glucose 5. fatty
acids converted to ketones - Answers - 2, 1, 4, 3, 5
12. During a home visit, the nurse evaluates care provided to a client with type 1
diabetes mellitus and history of metabolic acidosis. Which outcome indicates that the
care of this client has been successful? - Answers - The client is eating 3 balanced
meals per day with two snacks.
13. The nurse is planning care for the client with Cushing's syndrome who has been
admitted for complications related to the disease process. Which intervention should the
nurse plan for this client to improve the impaired gas exchange? - Answers - Schedule
nursing activities to allow for periods of rest.
14. A client with severe metabolic alkalosis is admitted to the unit. Which is priority for
the client? - Answers - Monitoring oxygen saturation
15. While reviewing laboratory results, the nurse notes that the clients potassium level is
2.8 mEq/L and chloride level is 100 mEq/L. Based on this data, which intervention does
the nurse plan for this client? - Answers - Discussing potassium chloride replacement
therapy with the healthcare provider.
16. A client is admitted with manifestations of metabolic alkalosis. Which diagnostic test
findings support the admitting diagnosis? Select all that apply. - Answers - Blood pH
7.47 and bicarbonate 34 mEq/L, Electrocardiogram changes consistent with
hypokalemia
17. The nurse assumes care for 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? - Answers - Respiratory acidosis
18. The nurse is caring for a client who has been admitted to the unit with respiratory
failure and respiratory acidosis. Which that are from the nursing history would the nurse
suspect contributed to the client's current state of health? - Answers - Aspiration
pneumonia
19. A client is admitted to the emergency department for treatment of an overdose. The
clients arterial blood gas results indicate acute respiratory acidosis. Which substance
, found in the nurses review of the toxicology analysis is most likely the cause for the
client's current condition? - Answers - Oxycodone
20. The nurse is preparing to analyze a client's arterial blood gas results. List the steps
in the order that the nurse should follow when analyzing this laboratory test.
1. Look at the PaCO2. 2. Look at the pH. 3. Evaluate the relationship between pH and
PaCO2.4. Look for compensation.5. Evaluate the pH, HCO3, and base excess for a
possible metabolic problem.6. Look at the bicarbonate.7. Evaluate oxygenation. -
Answers - 2, 1, 3, 6, 5, 4, 7
21. A parent calls the clinic and reports to a nurse that his 2 month old infant is hungry
more than usual but is vomiting immediately after eating. Which of the following
responses should the nurse make? - Answers - "Bring your baby into the clinic today"
22. A client is admitted to the hospital with sudden, severe abdominal pain. The client is
diagnosed with respiratory alkalosis. Which arterial blood gas value does the nurse
document to support this diagnosis? - Answers - pH is 7.47 and paco2 is 25
23. The client is admitted to the emergency department with symptoms of a panic
attack, including hyperventilation. Based on this data, the nurse plans care for which
health problem? - Answers - Respiratory alkalosis
24. The nurse is planning care for a client who has been admitted to the unit with a
salicyclate overdose. When preparing the plan of care, the nurse considers switch to be
a priority nursing diagnosis? - Answers - Ineffective breathing pattern
25. The client with an anxiety disorder is ready to be discharged from the unit. What
should the nurse plan to teach this client and family in preparation for discharge? Select
all that apply. - Answers - Refer the client for counseling, Teach the client the signs of
impending panic attack, Instruct the client to breathe slowly
26. The nurse is caring for the client with a history of anxiety who is experiencing chest
pain, palpitations and dyspnea. Which intervention would be a priority for this client? -
Answers - Reassuring the client that symptoms will resolve
27. The nurse is caring for a client who is 3 days post-operative following an emergency
appendectomy. The nurse is reviewing the client's lab values and notes that the clients
calcium levels have increased since before surgery. Which intervention should the
nurse Implement to decrease the client's possibility of developing hypercalcemia? -
Answers - Assist the client to ambulate around the room at least three times daily
28. A nurse is reviewing the laboratory report of a client and identifies a serum
potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan
to administer? - Answers - Sodium polystyrene
QUESTIONS & VERIFIED ANSWERS
1. A nurse is admitting a client who reports flu like symptoms with dysrhythmias
hyperactive reflexes and a new onset of confusion. The nurse should recognize that the
client is experience which of the following conditions? - Answers - Metabolic alkalosis
2. A nurse is caring for a client who has metabolic alkalosis. For which of the following
clinical manifestations should the nurse monitor? (select all that apply.) - Answers -
bicarbonate excess, circumoral paresthesia
3. A nurse is reviewing the medical records of four clients who have an acid base
imbalance. The nurse should recognize that which of the following clients is at risk for
metabolic acidosis? - Answers - Patient who has diarrhea
4. The nurse is reviewing the laboratory values of a client who has respiratory acidosis.
Which of the following findings should the nurse expect? - Answers - PaCO2 50 mm Hg
5. The client is brought to the emergency department after passing out in the local
department store. The client has been fasting and has ketones in the urine. Which acid-
base imbalance will the nurse expect to assess in the client? - Answers - Metabolic
acidosis
6. The patient is hyperventilating from anxiety and abdominal pain. Which assessment
findings should the nurse attribute to respiratory alkalosis? (select all that apply) -
Answers - Tingling in fingertips, Numbness around mouth, Cramping in feet
7. Which statement said by patients indicates that the nurse is teaching regarding
prevention of acid base imbalances is successful? (Select all that apply) - Answers - "I
should take my insulin on time every day," "My aspirin is on a high shelf away from
children," "I have reliable transportation to dialysis sessions"
8. The nurse is analyzing the client's arterial blood gas report, which reveals a pH of
6.58. The client has just suffered a cardiac arrest. Which consequences of this pH value
does the nurse consider for this client? - Answers - Decreased cardiac output
9. The mother of a one month old infant calls the nurse who works in the health clinic.
The mother is concerned because the infant has had vomiting and diarrhea for one day.
The nurse knows that this infant is at risk for metabolic acidosis. Which is the priority
nursing action? - Answers - Instruct the mother to bring the infant to the clinic for
evaluation.
,10. A client with metabolic acidosis has been admitted to the unit from the emergency
department. The client is experiencing confusion and weakness. Which nursing
intervention is a priority for this client? - Answers - Protecting the client from injury
11. The nurse is preparing to teach a client with type 1 diabetes mellitus on the
mechanism behind the development of ketoacidosis. List the order in which the nurse
should provide the information 1. production of lactate and hydrogen ions 2. tissue
hypoxemia 3. breakdown of fatty tissue 4. reduction and intracellular glucose 5. fatty
acids converted to ketones - Answers - 2, 1, 4, 3, 5
12. During a home visit, the nurse evaluates care provided to a client with type 1
diabetes mellitus and history of metabolic acidosis. Which outcome indicates that the
care of this client has been successful? - Answers - The client is eating 3 balanced
meals per day with two snacks.
13. The nurse is planning care for the client with Cushing's syndrome who has been
admitted for complications related to the disease process. Which intervention should the
nurse plan for this client to improve the impaired gas exchange? - Answers - Schedule
nursing activities to allow for periods of rest.
14. A client with severe metabolic alkalosis is admitted to the unit. Which is priority for
the client? - Answers - Monitoring oxygen saturation
15. While reviewing laboratory results, the nurse notes that the clients potassium level is
2.8 mEq/L and chloride level is 100 mEq/L. Based on this data, which intervention does
the nurse plan for this client? - Answers - Discussing potassium chloride replacement
therapy with the healthcare provider.
16. A client is admitted with manifestations of metabolic alkalosis. Which diagnostic test
findings support the admitting diagnosis? Select all that apply. - Answers - Blood pH
7.47 and bicarbonate 34 mEq/L, Electrocardiogram changes consistent with
hypokalemia
17. The nurse assumes care for 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? - Answers - Respiratory acidosis
18. The nurse is caring for a client who has been admitted to the unit with respiratory
failure and respiratory acidosis. Which that are from the nursing history would the nurse
suspect contributed to the client's current state of health? - Answers - Aspiration
pneumonia
19. A client is admitted to the emergency department for treatment of an overdose. The
clients arterial blood gas results indicate acute respiratory acidosis. Which substance
, found in the nurses review of the toxicology analysis is most likely the cause for the
client's current condition? - Answers - Oxycodone
20. The nurse is preparing to analyze a client's arterial blood gas results. List the steps
in the order that the nurse should follow when analyzing this laboratory test.
1. Look at the PaCO2. 2. Look at the pH. 3. Evaluate the relationship between pH and
PaCO2.4. Look for compensation.5. Evaluate the pH, HCO3, and base excess for a
possible metabolic problem.6. Look at the bicarbonate.7. Evaluate oxygenation. -
Answers - 2, 1, 3, 6, 5, 4, 7
21. A parent calls the clinic and reports to a nurse that his 2 month old infant is hungry
more than usual but is vomiting immediately after eating. Which of the following
responses should the nurse make? - Answers - "Bring your baby into the clinic today"
22. A client is admitted to the hospital with sudden, severe abdominal pain. The client is
diagnosed with respiratory alkalosis. Which arterial blood gas value does the nurse
document to support this diagnosis? - Answers - pH is 7.47 and paco2 is 25
23. The client is admitted to the emergency department with symptoms of a panic
attack, including hyperventilation. Based on this data, the nurse plans care for which
health problem? - Answers - Respiratory alkalosis
24. The nurse is planning care for a client who has been admitted to the unit with a
salicyclate overdose. When preparing the plan of care, the nurse considers switch to be
a priority nursing diagnosis? - Answers - Ineffective breathing pattern
25. The client with an anxiety disorder is ready to be discharged from the unit. What
should the nurse plan to teach this client and family in preparation for discharge? Select
all that apply. - Answers - Refer the client for counseling, Teach the client the signs of
impending panic attack, Instruct the client to breathe slowly
26. The nurse is caring for the client with a history of anxiety who is experiencing chest
pain, palpitations and dyspnea. Which intervention would be a priority for this client? -
Answers - Reassuring the client that symptoms will resolve
27. The nurse is caring for a client who is 3 days post-operative following an emergency
appendectomy. The nurse is reviewing the client's lab values and notes that the clients
calcium levels have increased since before surgery. Which intervention should the
nurse Implement to decrease the client's possibility of developing hypercalcemia? -
Answers - Assist the client to ambulate around the room at least three times daily
28. A nurse is reviewing the laboratory report of a client and identifies a serum
potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan
to administer? - Answers - Sodium polystyrene
