CHA FINAL EXAM QUESTIONS & ANSWERS
While reviewing a client's lab results, a nurse notes a serum calcium level of 8.0 mg/dL.
Which of the following actions should the nurse take?
a. Implement seizure precautions
b. Administer Phosphate
c. Initiate diuretic therapy
d. Prepare the client for hemodialysis - Answers - a. Implement seizure precautions
The client is at risk for seizures due to low excitation threshold as a result of a
decreased calcium level. The nurse should initiate seizure precautions to prevent injury
A nurse is preparing to administer oral potassium for a client who has a potassium level
of 5.5 mEq/L. Which of the following actions should the nurse take first?
a. Administer a hypertonic solution.
b. Repeat the potassium level.
c. Withhold the medication.
d. Monitor for paresthesia - Answers - c. Withhold the medication.
A nurse is assessing a client who has respiratory acidosis. Which of the following
findings should the nurse expect?
a. Confusion
b. Peripheral edema
c. Facial flushing
d. Hyperreflexia - Answers - a. Confusion
A client who has respiratory acidosis will experience confusion from a lack of cerebral
perfusion. If acidosis is not reversed, the client's level of consciousness will decrease
and coma may occur.
A nurse is teaching nutritional strategies to a client who has low serum calcium level
and an allergy to milk. Which of the following statements by the client indicates an
understanding of the teaching?
a. "I will eat more cheese because I can't drink milk."
b. "I need to avoid foods with vitamin D because I am allergic to milk."
c. "I will stop taking my calcium supplements if they irritate my stomach."
d. "I will add broccoli and kale to my diet." - Answers - d. "I will add broccoli and kale to
my diet."
,The nurse should recommend that the client consume broccoli and kale, which are good
sources of calcium, as alternatives to dairy products.
A nurse is reviewing ABG results for four clients. Which of the following findings should
the nurse identify as metabolic acidosis?
a. pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L
b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L
c. pH 7.36, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 26 mEq/L
d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L - Answers - d. pH
7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L
A pH below 7.35 is an indication of acidosis. HCO3- below 22 mEq/L is an indication of
metabolic acidosis.
The greatest risk to the client is bradycardia, hypotension, and life-threatening cardiac
complications due to hyperkalemia, defined as a potassium level above 5.0 mEq/L.
Therefore, the nurse's priority action is to withhold the oral potassium and notify the
provider
A nurse is reviewing the lab report of a client who has fluid volume excess. Which of the
following lab values should the nurse expect?
a. Hemoglobin 20 g/dL
b. Hematocrit 34%
c. BUN 25 mg/dL
d. Urine specific gravity 1.050 - Answers - b. Hematocrit 34%
The nurse should identify that a client who has fluid volume excess can have a
hematocrit level that is below the expected reference range of 37 to 47% for females or
42 to 52% for males. Fluid volume excess can cause hemodilution and a decreased
hematocrit level.
A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the
following findings is the priority for the nurse to assess?
a. Deep-tendon reflexes
b. Cardiac rhythm
c. Peripheral sensation
d. Bowel sounds - Answers - b. Cardiac rhythm
When using the airway, breathing, circulation approach to client care, the nurse should
first assess the client's cardiac rhythm because this total serum calcium level is below
,the expected reference range. Hypocalcemia can cause ECG changes, bradycardia, or
tachycardia.
A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The
nurse should plan to monitor the client for which of the following findings?
a. Hyperactive deep-tendon reflexes
b. Orthostatic hypotension
c. Rapid, deep respirations
d. Strong, bounding pulse - Answers - b. Orthostatic hypotension
The nurse should plan to monitor the client for orthostatic hypotension, which places
him at risk for falls. Orthostatic hypotension is a manifestation of hypokalemia.
A nurse is admitting a client who has status asthmaticus. The client's ABG results are:
pH: 7.32
paO2: 74 mmHg
PaCO2: 56 mmHg
HCO3: 26 mEq/L
The nurse should interpret these lab values as which of the following imbalances?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis - Answers - a. Respiratory acidosis
Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2,
an elevated PaCO2, and an HCO3- within the expected reference range. These
laboratory values indicate respiratory acidosis.
A nurse is assessing a client who is using PCA following a thoracotomy. The client is
short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG
results are:
pH 7.52
PaO2: 89 mmHg
PaCO2: 28 mmHg
HCO3: 24 mEq/L
Which of the following actions should the nurse take?
a. Instruct the client to cough forcefully.
b. Assist the client with ambulation.
c. Provide calming interventions.
d. Discontinue the PCA. - Answers - c. Provide calming interventions.
, The client's respiratory rate is above the expected range. Calming the client should
decrease the respiratory rate, which will cause the client's carbon dioxide levels to
increase to expected levels of 35 to 45 mm Hg and lower the pH to expected levels of
7.35 to 7.45. The nurse should instruct the client to breathe slowly.
A nurse is assessing a client with a phosphorus level of 2.4 mg/dL. Which of the
following should the nurse expect?
a. Hepatic failure
b. Abdominal pain
c. Slow peripheral pulses
d. Increase in cardiac output - Answers - c. Slow peripheral pulses
This phosphorus level is below the expected reference range. The nurse should expect
the client to have slow peripheral pulses. The nurse might also find that the client's
pulses are difficult to find and easy to block.
A nurse is caring for a client who reports difficulty breathing and tingling in both hands.
His respiratory rate is 36/min and he appears very restless. Which of the following
values should the nurse anticipate to be outside of the expected reference range if the
client is experiencing respiratory alkalosis?
a. PaO2
b. PaCO2
c. Sodium
d. Bicarbonate - Answers - b. PaCO2
The nurse should anticipate that a client who has respiratory alkalosis will have a
decreased PaCO2 level due to hyperventilation.
The nurse should anticipate that a client who has respiratory alkalosis will have a PaO2
level within the expected reference range.
The nurse should anticipate that a client who has respiratory alkalosis will have a
sodium level within the expected reference range.
The nurse should anticipate that a client who has respiratory alkalosis will have a
bicarbonate level within the expected reference range. The bicarbonate level is
increased in metabolic alkalosis.
A nurse is admitting a client who takes 40mg furosemide daily for heart failure and has
experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the
following medications should the nurse prepare to administer?
a. Sodium polystyrene sulfonate 30 g/day
While reviewing a client's lab results, a nurse notes a serum calcium level of 8.0 mg/dL.
Which of the following actions should the nurse take?
a. Implement seizure precautions
b. Administer Phosphate
c. Initiate diuretic therapy
d. Prepare the client for hemodialysis - Answers - a. Implement seizure precautions
The client is at risk for seizures due to low excitation threshold as a result of a
decreased calcium level. The nurse should initiate seizure precautions to prevent injury
A nurse is preparing to administer oral potassium for a client who has a potassium level
of 5.5 mEq/L. Which of the following actions should the nurse take first?
a. Administer a hypertonic solution.
b. Repeat the potassium level.
c. Withhold the medication.
d. Monitor for paresthesia - Answers - c. Withhold the medication.
A nurse is assessing a client who has respiratory acidosis. Which of the following
findings should the nurse expect?
a. Confusion
b. Peripheral edema
c. Facial flushing
d. Hyperreflexia - Answers - a. Confusion
A client who has respiratory acidosis will experience confusion from a lack of cerebral
perfusion. If acidosis is not reversed, the client's level of consciousness will decrease
and coma may occur.
A nurse is teaching nutritional strategies to a client who has low serum calcium level
and an allergy to milk. Which of the following statements by the client indicates an
understanding of the teaching?
a. "I will eat more cheese because I can't drink milk."
b. "I need to avoid foods with vitamin D because I am allergic to milk."
c. "I will stop taking my calcium supplements if they irritate my stomach."
d. "I will add broccoli and kale to my diet." - Answers - d. "I will add broccoli and kale to
my diet."
,The nurse should recommend that the client consume broccoli and kale, which are good
sources of calcium, as alternatives to dairy products.
A nurse is reviewing ABG results for four clients. Which of the following findings should
the nurse identify as metabolic acidosis?
a. pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L
b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L
c. pH 7.36, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 26 mEq/L
d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L - Answers - d. pH
7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L
A pH below 7.35 is an indication of acidosis. HCO3- below 22 mEq/L is an indication of
metabolic acidosis.
The greatest risk to the client is bradycardia, hypotension, and life-threatening cardiac
complications due to hyperkalemia, defined as a potassium level above 5.0 mEq/L.
Therefore, the nurse's priority action is to withhold the oral potassium and notify the
provider
A nurse is reviewing the lab report of a client who has fluid volume excess. Which of the
following lab values should the nurse expect?
a. Hemoglobin 20 g/dL
b. Hematocrit 34%
c. BUN 25 mg/dL
d. Urine specific gravity 1.050 - Answers - b. Hematocrit 34%
The nurse should identify that a client who has fluid volume excess can have a
hematocrit level that is below the expected reference range of 37 to 47% for females or
42 to 52% for males. Fluid volume excess can cause hemodilution and a decreased
hematocrit level.
A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the
following findings is the priority for the nurse to assess?
a. Deep-tendon reflexes
b. Cardiac rhythm
c. Peripheral sensation
d. Bowel sounds - Answers - b. Cardiac rhythm
When using the airway, breathing, circulation approach to client care, the nurse should
first assess the client's cardiac rhythm because this total serum calcium level is below
,the expected reference range. Hypocalcemia can cause ECG changes, bradycardia, or
tachycardia.
A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The
nurse should plan to monitor the client for which of the following findings?
a. Hyperactive deep-tendon reflexes
b. Orthostatic hypotension
c. Rapid, deep respirations
d. Strong, bounding pulse - Answers - b. Orthostatic hypotension
The nurse should plan to monitor the client for orthostatic hypotension, which places
him at risk for falls. Orthostatic hypotension is a manifestation of hypokalemia.
A nurse is admitting a client who has status asthmaticus. The client's ABG results are:
pH: 7.32
paO2: 74 mmHg
PaCO2: 56 mmHg
HCO3: 26 mEq/L
The nurse should interpret these lab values as which of the following imbalances?
a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis - Answers - a. Respiratory acidosis
Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2,
an elevated PaCO2, and an HCO3- within the expected reference range. These
laboratory values indicate respiratory acidosis.
A nurse is assessing a client who is using PCA following a thoracotomy. The client is
short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG
results are:
pH 7.52
PaO2: 89 mmHg
PaCO2: 28 mmHg
HCO3: 24 mEq/L
Which of the following actions should the nurse take?
a. Instruct the client to cough forcefully.
b. Assist the client with ambulation.
c. Provide calming interventions.
d. Discontinue the PCA. - Answers - c. Provide calming interventions.
, The client's respiratory rate is above the expected range. Calming the client should
decrease the respiratory rate, which will cause the client's carbon dioxide levels to
increase to expected levels of 35 to 45 mm Hg and lower the pH to expected levels of
7.35 to 7.45. The nurse should instruct the client to breathe slowly.
A nurse is assessing a client with a phosphorus level of 2.4 mg/dL. Which of the
following should the nurse expect?
a. Hepatic failure
b. Abdominal pain
c. Slow peripheral pulses
d. Increase in cardiac output - Answers - c. Slow peripheral pulses
This phosphorus level is below the expected reference range. The nurse should expect
the client to have slow peripheral pulses. The nurse might also find that the client's
pulses are difficult to find and easy to block.
A nurse is caring for a client who reports difficulty breathing and tingling in both hands.
His respiratory rate is 36/min and he appears very restless. Which of the following
values should the nurse anticipate to be outside of the expected reference range if the
client is experiencing respiratory alkalosis?
a. PaO2
b. PaCO2
c. Sodium
d. Bicarbonate - Answers - b. PaCO2
The nurse should anticipate that a client who has respiratory alkalosis will have a
decreased PaCO2 level due to hyperventilation.
The nurse should anticipate that a client who has respiratory alkalosis will have a PaO2
level within the expected reference range.
The nurse should anticipate that a client who has respiratory alkalosis will have a
sodium level within the expected reference range.
The nurse should anticipate that a client who has respiratory alkalosis will have a
bicarbonate level within the expected reference range. The bicarbonate level is
increased in metabolic alkalosis.
A nurse is admitting a client who takes 40mg furosemide daily for heart failure and has
experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the
following medications should the nurse prepare to administer?
a. Sodium polystyrene sulfonate 30 g/day
