NURS 2873 Exam 3 (2) verified questions with correct detailed
answers A+ Grade
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
- correct answer 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.
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
- correct answer 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.
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
- correct answer 3
The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic acidosis from
bicarbonate loss.
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
- correct answer 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.
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
- correct answer 4
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
- correct answer 1
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%
- correct answer 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.
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?
- correct answer 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.
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
- correct answer 2
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
- correct answer 1, 2, 3, 4
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
- correct answer 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.
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.)
answers A+ Grade
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
- correct answer 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.
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
- correct answer 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.
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
- correct answer 3
The pancreas secretes bicarbonate; a draining pancreatic fistula could cause metabolic acidosis from
bicarbonate loss.
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
- correct answer 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.
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
- correct answer 4
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
- correct answer 1
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%
- correct answer 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.
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?
- correct answer 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.
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
- correct answer 2
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
- correct answer 1, 2, 3, 4
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
- correct answer 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.
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.)
