, Question 1
A client with severe vomiting and prolonged nasogastric suctioning has an
arterial blood gas: pH 7.48, PaCO2 40 mm Hg, HCO3- 30 mEq/L. Which
acid-base imbalance does the nurse identify?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
Correct Answer: A - Metabolic alkalosis
RATIONALE
The elevated pH and HCO3- with normal PaCO2 indicate metabolic
alkalosis, commonly caused by loss of gastric acid. Respiratory
alkalosis would show low PaCO2, and metabolic acidosis would show
low HCO3- and pH. The normal PaCO2 rules out respiratory causes.
Question 2
Which assessment finding is the most sensitive early indicator of increased
intracranial pressure in a client with a traumatic brain injury?
A. Decreased level of consciousness
B. Pupillary dilation
C. Decerebrate posturing
D. Cushing's triad
Correct Answer: A - Decreased level of consciousness
RATIONALE
A change in level of consciousness is the earliest and most reliable
indicator of rising ICP. Pupillary changes, posturing, and Cushing's
triad occur later as herniation progresses. Early recognition allows
timely intervention.
Page 2
, Question 3
A client receiving furosemide for heart failure reports muscle weakness and
palpitations. Which laboratory value should the nurse review first?
A. Serum potassium
B. Serum sodium
C. Serum calcium
D. Serum magnesium
Correct Answer: A - Serum potassium
RATIONALE
Loop diuretics like furosemide cause potassium loss, leading to
hypokalemia, which manifests as muscle weakness and dysrhythmias.
While other electrolytes can be affected, potassium is the priority due
to cardiac risk. Sodium, calcium, and magnesium are less directly
implicated in these symptoms.
Question 4
The nurse is caring for a client with a new colostomy. Which stoma assessment
finding requires immediate notification of the provider?
A. Dusky blue-black coloration
B. Beefy red and moist
C. Slight bleeding when touched
D. Protruding 1 cm above skin
Correct Answer: A - Dusky blue-black coloration
RATIONALE
A dusky blue-black stoma indicates ischemia and possible necrosis,
requiring immediate intervention. A beefy red, moist stoma is normal,
as is slight bleeding from friable mucosa. Protrusion is a normal
variation.
Page 3
, Question 5
A client with type 1 diabetes has a blood glucose of 45 mg/dL and is
unresponsive. After administering glucagon, which action should the nurse
take next?
A. Recheck blood glucose in 15 minutes
B. Administer 50% dextrose IV push
C. Give oral glucose gel
D. Start a dextrose infusion
Correct Answer: A - Recheck blood glucose in 15 minutes
RATIONALE
After glucagon administration, the nurse should recheck blood glucose
in 15 minutes to evaluate effectiveness. IV dextrose is used if the
client has IV access and is unresponsive, but glucagon is given first if
no IV. Oral glucose is contraindicated in an unresponsive client.
Question 6
Which finding in a client with a chest tube indicates a need for immediate
intervention?
A. Continuous bubbling in the water-seal chamber
B. Tidaling in the water-seal chamber
C. Intermittent bubbling in the suction control chamber
D. Bloody drainage of 50 mL in the first hour
Correct Answer: A - Continuous bubbling in the water-seal
chamber
RATIONALE
Continuous bubbling in the water-seal chamber indicates an air leak,
which can lead to ineffective lung expansion. Tidaling is normal with
respiration. Intermittent bubbling in suction control is expected, and
50 mL/hr drainage is within normal limits initially.
Page 4
A client with severe vomiting and prolonged nasogastric suctioning has an
arterial blood gas: pH 7.48, PaCO2 40 mm Hg, HCO3- 30 mEq/L. Which
acid-base imbalance does the nurse identify?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
Correct Answer: A - Metabolic alkalosis
RATIONALE
The elevated pH and HCO3- with normal PaCO2 indicate metabolic
alkalosis, commonly caused by loss of gastric acid. Respiratory
alkalosis would show low PaCO2, and metabolic acidosis would show
low HCO3- and pH. The normal PaCO2 rules out respiratory causes.
Question 2
Which assessment finding is the most sensitive early indicator of increased
intracranial pressure in a client with a traumatic brain injury?
A. Decreased level of consciousness
B. Pupillary dilation
C. Decerebrate posturing
D. Cushing's triad
Correct Answer: A - Decreased level of consciousness
RATIONALE
A change in level of consciousness is the earliest and most reliable
indicator of rising ICP. Pupillary changes, posturing, and Cushing's
triad occur later as herniation progresses. Early recognition allows
timely intervention.
Page 2
, Question 3
A client receiving furosemide for heart failure reports muscle weakness and
palpitations. Which laboratory value should the nurse review first?
A. Serum potassium
B. Serum sodium
C. Serum calcium
D. Serum magnesium
Correct Answer: A - Serum potassium
RATIONALE
Loop diuretics like furosemide cause potassium loss, leading to
hypokalemia, which manifests as muscle weakness and dysrhythmias.
While other electrolytes can be affected, potassium is the priority due
to cardiac risk. Sodium, calcium, and magnesium are less directly
implicated in these symptoms.
Question 4
The nurse is caring for a client with a new colostomy. Which stoma assessment
finding requires immediate notification of the provider?
A. Dusky blue-black coloration
B. Beefy red and moist
C. Slight bleeding when touched
D. Protruding 1 cm above skin
Correct Answer: A - Dusky blue-black coloration
RATIONALE
A dusky blue-black stoma indicates ischemia and possible necrosis,
requiring immediate intervention. A beefy red, moist stoma is normal,
as is slight bleeding from friable mucosa. Protrusion is a normal
variation.
Page 3
, Question 5
A client with type 1 diabetes has a blood glucose of 45 mg/dL and is
unresponsive. After administering glucagon, which action should the nurse
take next?
A. Recheck blood glucose in 15 minutes
B. Administer 50% dextrose IV push
C. Give oral glucose gel
D. Start a dextrose infusion
Correct Answer: A - Recheck blood glucose in 15 minutes
RATIONALE
After glucagon administration, the nurse should recheck blood glucose
in 15 minutes to evaluate effectiveness. IV dextrose is used if the
client has IV access and is unresponsive, but glucagon is given first if
no IV. Oral glucose is contraindicated in an unresponsive client.
Question 6
Which finding in a client with a chest tube indicates a need for immediate
intervention?
A. Continuous bubbling in the water-seal chamber
B. Tidaling in the water-seal chamber
C. Intermittent bubbling in the suction control chamber
D. Bloody drainage of 50 mL in the first hour
Correct Answer: A - Continuous bubbling in the water-seal
chamber
RATIONALE
Continuous bubbling in the water-seal chamber indicates an air leak,
which can lead to ineffective lung expansion. Tidaling is normal with
respiration. Intermittent bubbling in suction control is expected, and
50 mL/hr drainage is within normal limits initially.
Page 4
