Test Bank Nursing A Concept Based Approach to Learning 1 Volume
5th Edition By Pearson Education. .
Module 1: Acid-Base Balance
Question 1:
A client who has been fasting and has ketones in the urine is brought to
the emergency department (ED) unconscious. 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
Answer: A) Metabolic acidosis
Rationale: A client who is fasting is at risk for the development of
metabolic acidosis. The body recognizes fasting as starvation and
begins to metabolize its own fatty acids into ketones, which are
metabolic acids. This process directly leads to an accumulation of acids
in the body, lowering the blood pH. Starvation would not result in
respiratory alkalosis, metabolic alkalosis, or respiratory acidosis as the
primary imbalance .
,Question 2:
The nurse is caring for a client in the emergency department. Which
factors will the nurse identify that increase the client's risk for
metabolic acidosis? Select all that apply.
A) Abdominal fistulas
B) Chronic obstructive pulmonary disease
C) Pneumonia
D) Chronic renal failure
E) Hypovolemic shock
Answer: A, D, E
Rationale: Metabolic acidosis is rarely a primary disorder. It usually
develops during the course of another condition such as an abdominal
fistula (which can cause a loss of bicarbonate from the intestine),
chronic renal failure (which leads to an inability to excrete metabolic
acids), and hypovolemic shock (which causes a buildup of lactic acid
due to poor tissue perfusion). Chronic obstructive pulmonary disease
and pneumonia are respiratory conditions that primarily lead to
respiratory acidosis due to impaired gas exchange and CO2 retention .
,Question 3:
A client is admitted with exacerbation of chronic obstructive pulmonary
disease (COPD). Which noninvasive diagnostic test will the nurse
implement to know that the client is receiving enough oxygen?
A) Chest x-ray
B) Pulse oximeter
C) Arterial blood gases
D) Assessment of respiratory rate
Answer: B) Pulse oximeter
Rationale: A pulse oximeter provides a noninvasive method of
measuring oxygenation (oxygen saturation) in the blood. A chest x-ray
is not a nursing intervention. Arterial blood gases are an invasive
diagnostic test. Assessing the respiratory rate is important but is not a
diagnostic test and does not directly measure if the client is receiving
enough oxygen .
Module 5: Elimination
Question 4:
The nurse is caring for an older adult client on a medical-surgical unit.
The client tells the nurse, "I don't get any sleep at night because I have
, to get up and use the bathroom every couple of hours!" When
providing an explanation for the nocturia, which statement by the
nurse is the most appropriate?
A) "As you get older, there is a decrease in the number of nephrons."
B) "As you get older, there is a decrease in the blood supply to your
bladder."
C) "As you get older, you may have a decreased bladder capacity."
D) "As you get older, there is a decrease in cardiac output, causing
these symptoms."
Answer: C) "As you get older, you may have a decreased bladder
capacity."
Rationale: Approximately 70% of older women and 50% of older men
have to get up two or more times during the night to empty their
bladders due to decreased bladder capacity. A decrease in blood supply
causes an increase in urine concentration. A decrease in the number of
nephrons decreases the filtration rate. A decrease in cardiac output
decreases peripheral circulation, which would decrease urinary output
day or night .
Module 13: Mobility & Module 15: Oxygenation (Sample from test bank
structure)
5th Edition By Pearson Education. .
Module 1: Acid-Base Balance
Question 1:
A client who has been fasting and has ketones in the urine is brought to
the emergency department (ED) unconscious. 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
Answer: A) Metabolic acidosis
Rationale: A client who is fasting is at risk for the development of
metabolic acidosis. The body recognizes fasting as starvation and
begins to metabolize its own fatty acids into ketones, which are
metabolic acids. This process directly leads to an accumulation of acids
in the body, lowering the blood pH. Starvation would not result in
respiratory alkalosis, metabolic alkalosis, or respiratory acidosis as the
primary imbalance .
,Question 2:
The nurse is caring for a client in the emergency department. Which
factors will the nurse identify that increase the client's risk for
metabolic acidosis? Select all that apply.
A) Abdominal fistulas
B) Chronic obstructive pulmonary disease
C) Pneumonia
D) Chronic renal failure
E) Hypovolemic shock
Answer: A, D, E
Rationale: Metabolic acidosis is rarely a primary disorder. It usually
develops during the course of another condition such as an abdominal
fistula (which can cause a loss of bicarbonate from the intestine),
chronic renal failure (which leads to an inability to excrete metabolic
acids), and hypovolemic shock (which causes a buildup of lactic acid
due to poor tissue perfusion). Chronic obstructive pulmonary disease
and pneumonia are respiratory conditions that primarily lead to
respiratory acidosis due to impaired gas exchange and CO2 retention .
,Question 3:
A client is admitted with exacerbation of chronic obstructive pulmonary
disease (COPD). Which noninvasive diagnostic test will the nurse
implement to know that the client is receiving enough oxygen?
A) Chest x-ray
B) Pulse oximeter
C) Arterial blood gases
D) Assessment of respiratory rate
Answer: B) Pulse oximeter
Rationale: A pulse oximeter provides a noninvasive method of
measuring oxygenation (oxygen saturation) in the blood. A chest x-ray
is not a nursing intervention. Arterial blood gases are an invasive
diagnostic test. Assessing the respiratory rate is important but is not a
diagnostic test and does not directly measure if the client is receiving
enough oxygen .
Module 5: Elimination
Question 4:
The nurse is caring for an older adult client on a medical-surgical unit.
The client tells the nurse, "I don't get any sleep at night because I have
, to get up and use the bathroom every couple of hours!" When
providing an explanation for the nocturia, which statement by the
nurse is the most appropriate?
A) "As you get older, there is a decrease in the number of nephrons."
B) "As you get older, there is a decrease in the blood supply to your
bladder."
C) "As you get older, you may have a decreased bladder capacity."
D) "As you get older, there is a decrease in cardiac output, causing
these symptoms."
Answer: C) "As you get older, you may have a decreased bladder
capacity."
Rationale: Approximately 70% of older women and 50% of older men
have to get up two or more times during the night to empty their
bladders due to decreased bladder capacity. A decrease in blood supply
causes an increase in urine concentration. A decrease in the number of
nephrons decreases the filtration rate. A decrease in cardiac output
decreases peripheral circulation, which would decrease urinary output
day or night .
Module 13: Mobility & Module 15: Oxygenation (Sample from test bank
structure)
