NURS 2873 Exam 3 (2) | UPDATED Questions with 100%
Verified Answers
Q1: The nurse is assessing a patient who has diabetic ketoacidosis.
Her assessment reveals tachycardia, lethargy, and
hyperventilation. Treatment for the ketoacidosis has been
initiated. What should the nurse do about the hypoventilation?
1. Request an order for pain medication and oxygen at 6 L/min
2. Lubricate the patient's lips and allow continued
hyperventilation
3. Have the patient breathe into a paper bag to stop
hyperventilating
4. Contact the physician immediately regarding this
complication
A: 3
Hyperventilation is a compensatory response to metabolic acidosis and should be
allowed to continue because it helps move the blood pH toward the normal range.
Lubricating the lips is a supportive nursing intervention that prevents drying and cracking
of the lips during hyperventilation.
Q2: A patient is having her first severe, acute asthma episode. It
began 2 hours ago. What blood gas values should the nurse
expect to see?
1. pH high, PaCO2 high, HCO3- high
2. pH low, PaCO2 low, HCO3- low
3. pH low, PaCO2 high, HCO3- high
4. pH low, PaCO2 high, HCO3- normal
A: 4
A severe acute asthma episode impairs the excretion of carbonic acid, causing
respiratory acidosis with a high PaCO2 and a low pH. Renal compensation takes longer
than 2 hours to occur, so the respiratory acidosis is uncompensated, leaving the HCO3
normal.
Q3: Which diagnosis indicates that the nurse should assess the
patient most carefully for development of metabolic acidosis?
1. Type B COPD and pneumonia
2. Acute meningococcal meningitis
3. A pancreatic fistula that is draining
4. Severe hyperaldosteronism
A: 3
The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic
acidosis from bicarbonate loss.
Q4: The patient has severe metabolic alkalosis. Which intervention
has the highest priority?
,1. Raise the side rails on the patient's bed
2. Measure the urine output and skin turgor
3. Teach the family about metabolic alkalosis
4. Administer IV NaHCO3 as ordered
A: 1
Severe metabolic alkalosis causes a decreased level of consciousness; raising the side
rails is a safety intervention in that situation. Safety interventions are a higher priority than
teaching.
Q5: The nurse in the emergency department is caring for a patient
who is on a ventilator. The patient's blood gases report reveals
a pH 7.48, PaO2 85, a PaCO2 32, and a HCO3 25. What is the
nurse's interpretation of these results?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
A: 4
Q6: The nurse is caring for a patient who suddenly becomes
lethargic and has an increase in the depth and rate of
respirations following ABG results: pH 7.32, PaO2 88, PaCO2
37, and HCO3 16. How should the nurse interpret these
results?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
A: 1
Q7: A patient is admitted to the ED with dehydration. ABG results
reveal that the patient has metabolic acidosis. Which of the
following signs or symptoms is the most likely cause of this
imbalance?
1. Hypoventilation
2. Vomiting and diarrhea
3. Serum potassium is 5.1
4. Arterial oxygen saturation is 91%
A: 2
Vomiting and diarrhea cause too much acid, the buffers have been overwhelmed, and
body fluids have too much acid. Acid excretion is not able to keep up with acid
production or intake.
,Q8: The nurse should ask which of the following questions to
detect the risk factors for metabolic acidosis?
(Select all that apply.)
1. Have you been vomiting today?
2. When did your kidneys stop working?
3. How long have you had diarrhea?
4. Are you still feeling short of breath?
5. What type of antacid did you take?
6. Which weight loss diet are you using?
A: 2, 3, 6
Risk factors for metabolic acidosis include decreased excretion of metabolic acid from
oliguria or anuria (kidneys are not working); excessive production of metabolic acid from
starvation ketoacidosis (inappropriate weight loss diet); and loss of bicarbonate from
diarrhea.
Q9: The nurse in the burn unit notes that the patient's skin is dry,
pale, and hard. The patient denies pain. What term would the
nurse use to document the burn depth?
1. First-degree skin destruction
2. Full-thickness skin destruction
3. Deep partial-thickness skin destruction
4. Superficial partial-thickness skin destruction
A: 2
Q10: The nurse in the skilled nursing facility is very busy and unable
to answer the call bell lights. Which tasks related to skin care
can the nurse delegate to the nursing assistant?
(Select all that apply.)
1. Applying over-the-counter lotions to skin that is not broken
2. Assisting the client with frequent turning to prevent pressure
ulcers
3. Covering the client who complains of being cold with more
blankets
4. Placing a sterile gauze pad over broken skin to contain
drainage
5. Assessing a patient complaining of an itching rash
A: 1, 2, 3, 4
Q11: The nurse would explain to a patient that effective treatments
for atopic pruritus include which treatments?
(Select all that apply.)
1. Oral steroids
2. Topical steroids
3. Oral antihistamines
4. Topical antihistamines
5. Topical petroleum ointment
, A: 1, 2
Oral and topical steroids may be given for acute cases of atopic pruritus. Oral and topical
antihistamines are not usually given, because they are ineffective and may cause further
irritation. Petroleum is also ineffective.
Q12: To help decrease the threat of melanoma in a blonde-haired,
fair-skinned patient at risk, which recommendations should the
nurse provide?
(Select all that apply.)
1. Wear sunglasses
2. Drink plenty of water
3. Eat plenty of foods high in vitamin K
4. Apply sunscreen 30 minutes prior to exposure
5. Consume fish oil and vitamin E
A: 1, 4, 5
Wearing sunglasses and using sunscreen are recommended by the National Cancer
Institute. Drinking water will help with heat exhaustion but will not prevent melanoma.
Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the
risk of developing melanoma; however, vitamin K can cause the blood to clot and has not
been indicated.
Q13: A nurse is instructing a nursing assistant in how to prevent
pressure ulcers in a frail elderly client. The nursing assistant
indicates that she understands the instruction when she agrees
to perform which actions?
(Select all that apply.)
1. Bathe and dry the skin vigorously to stimulate circulation
2. Keep the head of the bed elevated 30 degrees
3. Offer nutritional supplements and frequent snacks
4. Turn the patient at least every 2 hours
5. Maintain a cooler environment when bathing
A: 3, 4
The patient should be turned at least every 2 hours because permanent damage can
occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a
2-hour turning schedule, the patient must be turned more frequently. Protein-calorie
malnutrition is another major risk factor for developing pressure ulcers. Additional
supplements boost nutritional status, which is essential to healthy skin. Use of donut pads,
elevation of the head of the bed, and overstimulation of the skin may all stimulate, if not
actually encourage, dermal decline. Older adults are more prone to hypothermia if
bathed in a cooler environment.
Q14: A nurse is caring for a patient with second- and third-degree
burns to 50% of the body. The nurse prepares fluid
resuscitation based on knowledge of the Parkland (Baxter)
formula that includes which recommendation?
1. The total 24-hour fluid requirement should be administered
Verified Answers
Q1: The nurse is assessing a patient who has diabetic ketoacidosis.
Her assessment reveals tachycardia, lethargy, and
hyperventilation. Treatment for the ketoacidosis has been
initiated. What should the nurse do about the hypoventilation?
1. Request an order for pain medication and oxygen at 6 L/min
2. Lubricate the patient's lips and allow continued
hyperventilation
3. Have the patient breathe into a paper bag to stop
hyperventilating
4. Contact the physician immediately regarding this
complication
A: 3
Hyperventilation is a compensatory response to metabolic acidosis and should be
allowed to continue because it helps move the blood pH toward the normal range.
Lubricating the lips is a supportive nursing intervention that prevents drying and cracking
of the lips during hyperventilation.
Q2: A patient is having her first severe, acute asthma episode. It
began 2 hours ago. What blood gas values should the nurse
expect to see?
1. pH high, PaCO2 high, HCO3- high
2. pH low, PaCO2 low, HCO3- low
3. pH low, PaCO2 high, HCO3- high
4. pH low, PaCO2 high, HCO3- normal
A: 4
A severe acute asthma episode impairs the excretion of carbonic acid, causing
respiratory acidosis with a high PaCO2 and a low pH. Renal compensation takes longer
than 2 hours to occur, so the respiratory acidosis is uncompensated, leaving the HCO3
normal.
Q3: Which diagnosis indicates that the nurse should assess the
patient most carefully for development of metabolic acidosis?
1. Type B COPD and pneumonia
2. Acute meningococcal meningitis
3. A pancreatic fistula that is draining
4. Severe hyperaldosteronism
A: 3
The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic
acidosis from bicarbonate loss.
Q4: The patient has severe metabolic alkalosis. Which intervention
has the highest priority?
,1. Raise the side rails on the patient's bed
2. Measure the urine output and skin turgor
3. Teach the family about metabolic alkalosis
4. Administer IV NaHCO3 as ordered
A: 1
Severe metabolic alkalosis causes a decreased level of consciousness; raising the side
rails is a safety intervention in that situation. Safety interventions are a higher priority than
teaching.
Q5: The nurse in the emergency department is caring for a patient
who is on a ventilator. The patient's blood gases report reveals
a pH 7.48, PaO2 85, a PaCO2 32, and a HCO3 25. What is the
nurse's interpretation of these results?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
A: 4
Q6: The nurse is caring for a patient who suddenly becomes
lethargic and has an increase in the depth and rate of
respirations following ABG results: pH 7.32, PaO2 88, PaCO2
37, and HCO3 16. How should the nurse interpret these
results?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
A: 1
Q7: A patient is admitted to the ED with dehydration. ABG results
reveal that the patient has metabolic acidosis. Which of the
following signs or symptoms is the most likely cause of this
imbalance?
1. Hypoventilation
2. Vomiting and diarrhea
3. Serum potassium is 5.1
4. Arterial oxygen saturation is 91%
A: 2
Vomiting and diarrhea cause too much acid, the buffers have been overwhelmed, and
body fluids have too much acid. Acid excretion is not able to keep up with acid
production or intake.
,Q8: The nurse should ask which of the following questions to
detect the risk factors for metabolic acidosis?
(Select all that apply.)
1. Have you been vomiting today?
2. When did your kidneys stop working?
3. How long have you had diarrhea?
4. Are you still feeling short of breath?
5. What type of antacid did you take?
6. Which weight loss diet are you using?
A: 2, 3, 6
Risk factors for metabolic acidosis include decreased excretion of metabolic acid from
oliguria or anuria (kidneys are not working); excessive production of metabolic acid from
starvation ketoacidosis (inappropriate weight loss diet); and loss of bicarbonate from
diarrhea.
Q9: The nurse in the burn unit notes that the patient's skin is dry,
pale, and hard. The patient denies pain. What term would the
nurse use to document the burn depth?
1. First-degree skin destruction
2. Full-thickness skin destruction
3. Deep partial-thickness skin destruction
4. Superficial partial-thickness skin destruction
A: 2
Q10: The nurse in the skilled nursing facility is very busy and unable
to answer the call bell lights. Which tasks related to skin care
can the nurse delegate to the nursing assistant?
(Select all that apply.)
1. Applying over-the-counter lotions to skin that is not broken
2. Assisting the client with frequent turning to prevent pressure
ulcers
3. Covering the client who complains of being cold with more
blankets
4. Placing a sterile gauze pad over broken skin to contain
drainage
5. Assessing a patient complaining of an itching rash
A: 1, 2, 3, 4
Q11: The nurse would explain to a patient that effective treatments
for atopic pruritus include which treatments?
(Select all that apply.)
1. Oral steroids
2. Topical steroids
3. Oral antihistamines
4. Topical antihistamines
5. Topical petroleum ointment
, A: 1, 2
Oral and topical steroids may be given for acute cases of atopic pruritus. Oral and topical
antihistamines are not usually given, because they are ineffective and may cause further
irritation. Petroleum is also ineffective.
Q12: To help decrease the threat of melanoma in a blonde-haired,
fair-skinned patient at risk, which recommendations should the
nurse provide?
(Select all that apply.)
1. Wear sunglasses
2. Drink plenty of water
3. Eat plenty of foods high in vitamin K
4. Apply sunscreen 30 minutes prior to exposure
5. Consume fish oil and vitamin E
A: 1, 4, 5
Wearing sunglasses and using sunscreen are recommended by the National Cancer
Institute. Drinking water will help with heat exhaustion but will not prevent melanoma.
Green tea, fish oil, soy products, and vitamin E are thought to be helpful in minimizing the
risk of developing melanoma; however, vitamin K can cause the blood to clot and has not
been indicated.
Q13: A nurse is instructing a nursing assistant in how to prevent
pressure ulcers in a frail elderly client. The nursing assistant
indicates that she understands the instruction when she agrees
to perform which actions?
(Select all that apply.)
1. Bathe and dry the skin vigorously to stimulate circulation
2. Keep the head of the bed elevated 30 degrees
3. Offer nutritional supplements and frequent snacks
4. Turn the patient at least every 2 hours
5. Maintain a cooler environment when bathing
A: 3, 4
The patient should be turned at least every 2 hours because permanent damage can
occur in 2 hours or less. If skin assessment reveals a stage I ulcer while the patient is on a
2-hour turning schedule, the patient must be turned more frequently. Protein-calorie
malnutrition is another major risk factor for developing pressure ulcers. Additional
supplements boost nutritional status, which is essential to healthy skin. Use of donut pads,
elevation of the head of the bed, and overstimulation of the skin may all stimulate, if not
actually encourage, dermal decline. Older adults are more prone to hypothermia if
bathed in a cooler environment.
Q14: A nurse is caring for a patient with second- and third-degree
burns to 50% of the body. The nurse prepares fluid
resuscitation based on knowledge of the Parkland (Baxter)
formula that includes which recommendation?
1. The total 24-hour fluid requirement should be administered
