Nursing 192- Chapter 38 and 39 Questions With Complete
Solutions
A client 57 years of age is recovering in a hospital following a
bilateral mastectomy and breast reconstruction 2 day earlier.
Since her surgery, the client has been unwilling to mobilize
despite the nurse's education on the benefits of early
mobilization following surgery. The nurse would recognize that
the client's prolonged immobility creates a risk for
a) atelectasis
b) pneumothorax
c) hemothorax
d) tachypnea Correct Answers a) atelectasis
Prolonged bed rest can result in the incomplete lung expansion
and collapse of alveoli that characterize atelectasis. Immobility
is not commonly implicated in cases of pneumothorax or
hemothorax. Tachypnea, if present, would likely be a sign of
atelectasis rather than an independent finding.
A client admitted to the facility with a diagnosed metabolic
alkalosis based on arterial blood gas values. When obtaining the
client's history, which statement would the nurse interpret as a
possible underlying cause?
a) "i was breathing so fast because I was so anxious and in so
much pain"
b) "I've been taking antacids almost every 2 hours over the past
several days"
c) "I've had a fever for the past 3 days that just doesn't seem to
go away"
,d) "I've had a GI virus for the past 3 days with severe diarrhea"
Correct Answers b) "I've been taking antacids almost every 2
hours over the past several days"
Metabolic alkalosis occurs when there is excessive loss of body
acids or with unusal intake of alkaline substances. It can also
occur in conjunction with an ECF deficit or potassium deficit.
Vomiting or vigorous nasogastric suction frequently causes
metabolic alkalosis. Endocrine disorders and ingestion of large
amounts of antacids are other causes. Hyperventilation,
commonly caused by anxiety or pain, would lead to respiratory
alkalosis. Fever, which increases carbon dioxide excretion,
would also be associated with respiratory alkalosis. Severe
diarrhea is associated with metabolic acidosis.
A client admitted with heart failure requires monitoring of his
fluid status. Which method will provide the nurse with the best
indication of the client's fluid status?
a) daily weights
b) daily BUN and serum creatinine monitoring
c) output measurements
d) daily electrolyte monitoring Correct Answers a) daily
weights
Due to the possible numerous sources of inaccuracies in fluid
intake and output measurement, the record of a client's daily
weight may be more accurate measurement of a client's fluid
status. Lab tests are helpful in assessing kidney function and
electrolyte values, but do not provide the precise information on
fluid losses or gains as is provided by a daily weight. Output
measurements are not meaningful without intake measurements.
, A client is reporting slight shortness of breath and lung
auscultation reveals the presence of bilateral coarse crackles.
The nurse has applied supplementary oxygen by nasal cannula,
recognizing that the flow rate by this method should not exceed:
a) 6 L/min
b) 1 L/min
c) 4 L/min
d) 10 L/min Correct Answers a) 6 L/min
In general, if a flow rate of 6 L/minute fails to raise a client's
oxygen saturation level satisfactorily, a mask should be used.
A client is taking a diuretic such as furosemide. When
implementing client education, what information should be
included?
a) increased sodium levels
b) increased potassium levels
c) decreased potassium levels
d) decreased oxygen levels Correct Answers c) decreased
potassium levels
Many diuretics such as furosemide are potassium wasting;
hence, potassium levels are measured to detect hypokalemia.
A group of nursing students is reviewing information about
body fluid and locations. The students demonstrate
understanding of the material when they identify which of the
following as a function of intracellular fluid?
a) removal of waste
b) maintenance of blood volume
Solutions
A client 57 years of age is recovering in a hospital following a
bilateral mastectomy and breast reconstruction 2 day earlier.
Since her surgery, the client has been unwilling to mobilize
despite the nurse's education on the benefits of early
mobilization following surgery. The nurse would recognize that
the client's prolonged immobility creates a risk for
a) atelectasis
b) pneumothorax
c) hemothorax
d) tachypnea Correct Answers a) atelectasis
Prolonged bed rest can result in the incomplete lung expansion
and collapse of alveoli that characterize atelectasis. Immobility
is not commonly implicated in cases of pneumothorax or
hemothorax. Tachypnea, if present, would likely be a sign of
atelectasis rather than an independent finding.
A client admitted to the facility with a diagnosed metabolic
alkalosis based on arterial blood gas values. When obtaining the
client's history, which statement would the nurse interpret as a
possible underlying cause?
a) "i was breathing so fast because I was so anxious and in so
much pain"
b) "I've been taking antacids almost every 2 hours over the past
several days"
c) "I've had a fever for the past 3 days that just doesn't seem to
go away"
,d) "I've had a GI virus for the past 3 days with severe diarrhea"
Correct Answers b) "I've been taking antacids almost every 2
hours over the past several days"
Metabolic alkalosis occurs when there is excessive loss of body
acids or with unusal intake of alkaline substances. It can also
occur in conjunction with an ECF deficit or potassium deficit.
Vomiting or vigorous nasogastric suction frequently causes
metabolic alkalosis. Endocrine disorders and ingestion of large
amounts of antacids are other causes. Hyperventilation,
commonly caused by anxiety or pain, would lead to respiratory
alkalosis. Fever, which increases carbon dioxide excretion,
would also be associated with respiratory alkalosis. Severe
diarrhea is associated with metabolic acidosis.
A client admitted with heart failure requires monitoring of his
fluid status. Which method will provide the nurse with the best
indication of the client's fluid status?
a) daily weights
b) daily BUN and serum creatinine monitoring
c) output measurements
d) daily electrolyte monitoring Correct Answers a) daily
weights
Due to the possible numerous sources of inaccuracies in fluid
intake and output measurement, the record of a client's daily
weight may be more accurate measurement of a client's fluid
status. Lab tests are helpful in assessing kidney function and
electrolyte values, but do not provide the precise information on
fluid losses or gains as is provided by a daily weight. Output
measurements are not meaningful without intake measurements.
, A client is reporting slight shortness of breath and lung
auscultation reveals the presence of bilateral coarse crackles.
The nurse has applied supplementary oxygen by nasal cannula,
recognizing that the flow rate by this method should not exceed:
a) 6 L/min
b) 1 L/min
c) 4 L/min
d) 10 L/min Correct Answers a) 6 L/min
In general, if a flow rate of 6 L/minute fails to raise a client's
oxygen saturation level satisfactorily, a mask should be used.
A client is taking a diuretic such as furosemide. When
implementing client education, what information should be
included?
a) increased sodium levels
b) increased potassium levels
c) decreased potassium levels
d) decreased oxygen levels Correct Answers c) decreased
potassium levels
Many diuretics such as furosemide are potassium wasting;
hence, potassium levels are measured to detect hypokalemia.
A group of nursing students is reviewing information about
body fluid and locations. The students demonstrate
understanding of the material when they identify which of the
following as a function of intracellular fluid?
a) removal of waste
b) maintenance of blood volume
