PORTAGE LEARNING PATHOPHYSIOLOGY NURS 231 BIOD
331 FINAL EXAM & MODULE 1-10 EXAMS ACTUAL
QUESTIONS AND CORRECT ANSWERS WITH
EXPLANATIONS ALL VERSIONS LATEST UPDATE A GRADE
The nurse is caring for a client who has just been extubated after receiving
mechanical ventilation. Which action will the nurse delegate to unlicensed assistive
personnel?
a) Teach about incentive spirometer use.
b) Monitor vital signs every 5 minutes.
c) Adjust the nasal oxygen flow rate.
d) Keep the head of the bed elevated. - ANS... -d) Keep the head of the bed
elevated.
*Positioning clients is included in UAP education and scope of practice and can be
delegated. Client teaching is an activity performed by the professional nurse.
Although taking vital signs is an activity of the UAP, monitoring a potentially
unstable client is done by the RN. Adjusting oxygen flow rates requires complex
decision making and should be done by the RN.
A client was intubated 30 minutes ago for ARDS and possible sepsis. The
following prescriptions have been given for the client. In what sequence will the
nurse perform these actions:
1. Infuse levofloxacin (Levaquin) 500 mg IV
2. Obtain baseline aerobic and anaerobic sputum cultures
3. Teach the client and family methods of communicating
4. Analyze post-intubation arterial blood gases (ABGs)
a) 4, 3, 1, 2
b) 3, 4, 2, 1
c) 2, 1, 3, 4
d) 4, 2, 1, 3 - ANS... -d) 4, 2, 1, 3
*ABGs which evaluate oxygenation, ventilation, and pH would be analyzed 1st
before the other assessments/actions are carried out. A baseline of sputum cultures
,would then be obtained before anti-infective medications are administered. Then
levofloxacin can be given. Client and family education on communication methods
is important, but is the lowest priority.
The nurse is caring for postoperative clients at risk for hypovolemic shock. Which
condition represents an early symptom of shock?
a) Hypotension
b) Tachycardia
c) Bradypnea
d) Heart blocks - ANS... -b) Tachycardia
*HR and RR increase from the client's baseline level or a slight increase in
diastolic blood pressure may be the only objective manifestation of this early stage
of shock. Catecholamine release occurs early in shock as a compensation for fluid
loss so BP will be normal.
*Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the
heart.
Which problem in the clients below best demonstrates the highest risk for
hypovolemic shock?
a) Client with myocardial infarction
b) Client with syndrome of inappropriate antidiuretic hormone secretion
c) Client with severe ascites
d) Client receiving a blood transfusion - ANS... -c) Client with severe ascites
*Fluid shifts from vascular to intraabdominal may cause decreased circulating
blood volume and poor tissue perfusion.
*Myocardial infarction results in tissue necrosis in the heart muscle, but no blood
or fluid losses occur. Owing to excess antidiuretic hormone secretion, the client
with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.
The nurse is caring for a client in the refractory stage of cardiogenic shock. Which
intervention does the nurse consider?
a) Admission to rehabilitation hospital for ambulatory retraining
b) Discussion with family and provider regarding palliative care
c) Enrollment in a cardiac transplantation program
d) Collaboration with home care agency for return to home - ANS... -b) Discussion
with family and provider regarding palliative care
,*In this irreversible phase, therapy is not effective in saving the client's life, even if
the cause of shock is corrected and MAP temporarily returns to normal. A
discussion on palliative care would be considered. Rehabilitation or returning
home is unlikely. The client with sustained tissue hypoxia is not a candidate for
organ transplantation.
A client with shock has been started on dopamine at 12 mcg/kg/min. Which
response indicates a positive outcome?
a) Blood glucose 245
b) Serum creatinine 3.6
c) Hourly urine output 10 to 12 mL/hr
d) BP of 90/60 mm Hg and MAP of 70 - ANS... -d) Blood pressure 90/60 mm Hg
and mean arterial pressure 70
*A positive outcome of a Dopamine infusion started on a client with shock is a BP
of 90/60 and a MAP of 70. Dopamine improves blood flow by increasing
peripheral resistance, which increases BP. Urine output less than 30 mL/hr or 0.5
mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the
kidney and are a negative consequence of shock, not a positive response.
The client with which problem is at highest risk for hypovolemic shock?
a) Kidney stone
b) portal hypertension
c) Kidney failure
d) Arthritis and daily acetaminophen use - ANS... -b) portal hypertension
*With portal HTN, the portal vessels are under high pressure & are prone to
rupture, causing massive upper GI bleeding and hypovolemic shock.
*Although a kidney stone may cause hematuria, massive blood loss or
hypovolemia generally does not occur.
*As the kidneys fail, fluid is typically retained, causing FVE.
*NSAIDs like naproxen and ibuprofen may predispose the client to GI bleeding
and hypovolemia.
The client with which laboratory result is at risk for hemorrhagic shock?
a) Hemoglobin 8.2
b) PTT of 12.5 seconds
c) INR of 7.9
d) Platelets 170,000 - ANS... -c) INR of 7.9
, *Prolonged INR indicates that blood takes longer than normal to clot and increases
the risk for bleeding.
*PTT of 12.5 seconds is low and puts this client at risk for clotting. A platelet
value of 170,000 is normal and poses no risk for bleeding. Although a hemoglobin
of 8.2 is low, the client could have severe iron deficiency or could have received
medication affecting the bone marrow.
Which problem places a person at highest risk for septic shock?
a) Cirrhosis
b) Lung cancer
c) Kidney failure
d) 40% burn injury - ANS... -d) 40% burn injury
*A client with 40% burn injury is at highest risk for septic shock and possible
death. The skin forms the first barrier to prevent entry of organisms into the body.
Although the client with kidney failure has an increased risk for infection and
although pt has cirrhosis which the liver acts as a filter for pathogens, these clients
have intact skin, unlike the burned client. The client with lung cancer may be at
risk for increased secretions and infection, but risk is not as high as for a client
with open skin.
Match the lab profile with the most likely fluid imbalance like A) Fluid Volume
Deficit 2) Fluid Volume Excess
1) ____Na 148; Hct 40% yesterday, 49% today; serum osmolarity 308
2) ____Hgb 13.2 yesterday, 10.1 today; Urine specific gravity 1.001
3) ____BUN 45; Cr 0.7 - ANS... -1) A
2) B
3) A
The nurse is preparing to administer lisinopril (Zestril) to a patient with acute
coronary syndrome. Which of the following findings should prompt the nurse to
hold the medication and consult the healthcare provider?
a) Serum sodium level 134
b) Serum potassium 5.6
c) Heart rate 58
d) Blood pressure 125/78 - ANS... -b) Serum potassium 5.6
*ACE inhibitors can cause/exacerbate hyperkalemia.
331 FINAL EXAM & MODULE 1-10 EXAMS ACTUAL
QUESTIONS AND CORRECT ANSWERS WITH
EXPLANATIONS ALL VERSIONS LATEST UPDATE A GRADE
The nurse is caring for a client who has just been extubated after receiving
mechanical ventilation. Which action will the nurse delegate to unlicensed assistive
personnel?
a) Teach about incentive spirometer use.
b) Monitor vital signs every 5 minutes.
c) Adjust the nasal oxygen flow rate.
d) Keep the head of the bed elevated. - ANS... -d) Keep the head of the bed
elevated.
*Positioning clients is included in UAP education and scope of practice and can be
delegated. Client teaching is an activity performed by the professional nurse.
Although taking vital signs is an activity of the UAP, monitoring a potentially
unstable client is done by the RN. Adjusting oxygen flow rates requires complex
decision making and should be done by the RN.
A client was intubated 30 minutes ago for ARDS and possible sepsis. The
following prescriptions have been given for the client. In what sequence will the
nurse perform these actions:
1. Infuse levofloxacin (Levaquin) 500 mg IV
2. Obtain baseline aerobic and anaerobic sputum cultures
3. Teach the client and family methods of communicating
4. Analyze post-intubation arterial blood gases (ABGs)
a) 4, 3, 1, 2
b) 3, 4, 2, 1
c) 2, 1, 3, 4
d) 4, 2, 1, 3 - ANS... -d) 4, 2, 1, 3
*ABGs which evaluate oxygenation, ventilation, and pH would be analyzed 1st
before the other assessments/actions are carried out. A baseline of sputum cultures
,would then be obtained before anti-infective medications are administered. Then
levofloxacin can be given. Client and family education on communication methods
is important, but is the lowest priority.
The nurse is caring for postoperative clients at risk for hypovolemic shock. Which
condition represents an early symptom of shock?
a) Hypotension
b) Tachycardia
c) Bradypnea
d) Heart blocks - ANS... -b) Tachycardia
*HR and RR increase from the client's baseline level or a slight increase in
diastolic blood pressure may be the only objective manifestation of this early stage
of shock. Catecholamine release occurs early in shock as a compensation for fluid
loss so BP will be normal.
*Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the
heart.
Which problem in the clients below best demonstrates the highest risk for
hypovolemic shock?
a) Client with myocardial infarction
b) Client with syndrome of inappropriate antidiuretic hormone secretion
c) Client with severe ascites
d) Client receiving a blood transfusion - ANS... -c) Client with severe ascites
*Fluid shifts from vascular to intraabdominal may cause decreased circulating
blood volume and poor tissue perfusion.
*Myocardial infarction results in tissue necrosis in the heart muscle, but no blood
or fluid losses occur. Owing to excess antidiuretic hormone secretion, the client
with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.
The nurse is caring for a client in the refractory stage of cardiogenic shock. Which
intervention does the nurse consider?
a) Admission to rehabilitation hospital for ambulatory retraining
b) Discussion with family and provider regarding palliative care
c) Enrollment in a cardiac transplantation program
d) Collaboration with home care agency for return to home - ANS... -b) Discussion
with family and provider regarding palliative care
,*In this irreversible phase, therapy is not effective in saving the client's life, even if
the cause of shock is corrected and MAP temporarily returns to normal. A
discussion on palliative care would be considered. Rehabilitation or returning
home is unlikely. The client with sustained tissue hypoxia is not a candidate for
organ transplantation.
A client with shock has been started on dopamine at 12 mcg/kg/min. Which
response indicates a positive outcome?
a) Blood glucose 245
b) Serum creatinine 3.6
c) Hourly urine output 10 to 12 mL/hr
d) BP of 90/60 mm Hg and MAP of 70 - ANS... -d) Blood pressure 90/60 mm Hg
and mean arterial pressure 70
*A positive outcome of a Dopamine infusion started on a client with shock is a BP
of 90/60 and a MAP of 70. Dopamine improves blood flow by increasing
peripheral resistance, which increases BP. Urine output less than 30 mL/hr or 0.5
mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the
kidney and are a negative consequence of shock, not a positive response.
The client with which problem is at highest risk for hypovolemic shock?
a) Kidney stone
b) portal hypertension
c) Kidney failure
d) Arthritis and daily acetaminophen use - ANS... -b) portal hypertension
*With portal HTN, the portal vessels are under high pressure & are prone to
rupture, causing massive upper GI bleeding and hypovolemic shock.
*Although a kidney stone may cause hematuria, massive blood loss or
hypovolemia generally does not occur.
*As the kidneys fail, fluid is typically retained, causing FVE.
*NSAIDs like naproxen and ibuprofen may predispose the client to GI bleeding
and hypovolemia.
The client with which laboratory result is at risk for hemorrhagic shock?
a) Hemoglobin 8.2
b) PTT of 12.5 seconds
c) INR of 7.9
d) Platelets 170,000 - ANS... -c) INR of 7.9
, *Prolonged INR indicates that blood takes longer than normal to clot and increases
the risk for bleeding.
*PTT of 12.5 seconds is low and puts this client at risk for clotting. A platelet
value of 170,000 is normal and poses no risk for bleeding. Although a hemoglobin
of 8.2 is low, the client could have severe iron deficiency or could have received
medication affecting the bone marrow.
Which problem places a person at highest risk for septic shock?
a) Cirrhosis
b) Lung cancer
c) Kidney failure
d) 40% burn injury - ANS... -d) 40% burn injury
*A client with 40% burn injury is at highest risk for septic shock and possible
death. The skin forms the first barrier to prevent entry of organisms into the body.
Although the client with kidney failure has an increased risk for infection and
although pt has cirrhosis which the liver acts as a filter for pathogens, these clients
have intact skin, unlike the burned client. The client with lung cancer may be at
risk for increased secretions and infection, but risk is not as high as for a client
with open skin.
Match the lab profile with the most likely fluid imbalance like A) Fluid Volume
Deficit 2) Fluid Volume Excess
1) ____Na 148; Hct 40% yesterday, 49% today; serum osmolarity 308
2) ____Hgb 13.2 yesterday, 10.1 today; Urine specific gravity 1.001
3) ____BUN 45; Cr 0.7 - ANS... -1) A
2) B
3) A
The nurse is preparing to administer lisinopril (Zestril) to a patient with acute
coronary syndrome. Which of the following findings should prompt the nurse to
hold the medication and consult the healthcare provider?
a) Serum sodium level 134
b) Serum potassium 5.6
c) Heart rate 58
d) Blood pressure 125/78 - ANS... -b) Serum potassium 5.6
*ACE inhibitors can cause/exacerbate hyperkalemia.
