Nursing 113 Final Exam QUESTIONS
AND CORRECT ANSWERS
The nurse reviews the arterial blood gas results of a client with emphysema and notes that the
laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27
mEq/L. The nurse interprets that the client has which acid-base disturbance?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - CORRECT ANSWER 3. Respiratory Acidosis
Rationale: The normal pH is 7.35 to 7.45. Normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis,
the pH is low and Paco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values
identified in the question.
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client
is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG)
monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn
and the nurse reviews the results, expecting to note which finding?
1. A decreased pH and an increased Paco22
2. An increased pH and a decreased Paco23
3. A decreased pH and a decreased HCO3-4
4. An increased pH and an increased HCO3- - CORRECT ANSWER 4. An increased pH and
an increased HCO3-
Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic
alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms
experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a
respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects
a metabolic acidotic condition.
The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30
mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with
these ABG results? Select all that apply.
1. Nausea
,2. Confusion
3. Bradypnea
4. Tachycardia
5. Hyperkalemia
6. Light-headedness - CORRECT ANSWER 1,2,4,6
Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion
concentration that results from the accumulation of base or from a loss of acid without a comparable
loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory
system. Clinical manifestations of respiratory alkalosis include lethargy, light-headedness, confusion,
tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness
and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations
that are regular but abnormally slow. Hyperkalemia is associated with acidosis.
The nurse is caring for a client with several broken ribs. The client is most likely to experience what
type of acid-base imbalance?
1. Respiratory acidosis from inadequate ventilation
2. Respiratory alkalosis from anxiety and hyperventilation
3. Metabolic acidosis from calcium loss due to broken bones
4. Metabolic alkalosis from taking analgesics containing base products - CORRECT ANSWER
1. Respiratory acidosis from inadequate ventilation
Rationale: Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs
will have difficulty with breathing adequately and is at risk for hypoventilation and resultant
respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with
hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking
analgesics containing base products.
The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to
drain, the nurse anticipates that which measure would most likely be recommended to the client?
1. Strict bed rest
2. A myringotomy
3. A mastoidectomy
4. Diphenhydramine - CORRECT ANSWER 2. A myringotomy
,Rationale: A myringotomy is a surgical procedure that will allow fluid to drain from the middle ear
and may be necessary to treat acute otitis media. Strict bed rest is not necessary, although activity may
be restricted. Additionally, bed rest would not assist in reducing pressure or allowing fluid to drain. In
some recurrent and persistent cases, the mastoid bone is removed or partially removed for chronic
otitis media. Diphenhydramine is an antihistamine with antiemetic properties.
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client
statement reflects a need for further teaching?
1. " I can sit down to put on my pants and shoes."
2. " I try to exercise everyday and rest when I'm tired."
3. " My son removed all loose rugs from my bedroom."
4. " I don't need to use my walker to get to the bathroom." - CORRECT ANSWER 4. " I don't
need to use my walker to get to the bathroom."
Rationale: The client with Parkinson's disease would be instructed regarding safety measures in the
home. The client needs to use a walker as support to get to the bathroom because of bradykinesia. The
client needs to sit down to put on pants and shoes to prevent falling. The client needs to exercise every
day in the morning when energy levels are highest. The client needs to have all loose rugs in the home
removed to prevent falling.
A client is diagnosed with conjunctivitis, and the nurse provides information to the client about the
use of contact lenses. Which statement by the client would indicate the need for further information?
1. "I would not wear my contact lenses."
2. "New contact lenses need to be obtained."
3 ."My old contact lenses need to be discarded."
4. "My contact lenses can be worn if they are cleaned properly." - CORRECT ANSWER 4.
"My contact lenses can be worn if they are cleaned properly."
Rationale:If the client wears contact lenses, the client needs to be instructed to discontinue wearing
them until the infection has cleared completely. Securing new contact lenses will eliminate the chance
of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration.
The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is
necessary to determine information about which items as part of routine assessment of seizures?
Select all that apply.
1. Postictal status
, 2. Duration of the seizure
3. Changes in pupil size or eye deviation
4. Seizure progression and type of movements
5. What the client ate in the 2 hours preceding seizure activity - CORRECT ANSWER 1,2,3,4
Rationale: Typically seizure assessment includes the time the seizure began, parts of the body
affected, type of movements and progression of the seizure, change in pupil size or eye deviation or
nystagmus, client condition during the seizure, and postictal status. Determining what the client ate 2
hours prior to the seizure is not a component of seizure assessment.
A client with multiple sclerosis tells a home health care nurse about having increasing difficulty in
transferring from the bed to a chair. What is the initial nursing action?
1. Observe the client demonstrating the transfer technique.
2. Start a restorative nursing program before an injury occurs.
3. Seize the opportunity to discuss potential nursing home placement.
4. Determine the number of falls that the client has had in recent weeks. - CORRECT ANSWER
1. Observe the client demonstrating the transfer technique.
Rationale: Observation of the client's transfer technique is the initial intervention. Starting a
restorative program is important but not unless an assessment has been completed first. Discussing
nursing home placement would be inappropriate in view of the information provided in the question.
Determining the number of falls is another important intervention, but observing the transfer
technique needs to be done first.
The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse
has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the
nurse expect to note on assessment of the client's sacral area?
1. Intact skin
2. Full-thickness skin loss
3. Exposed bone, tendon, or muscle
4. Partial-thickness skin loss of the dermis - CORRECT ANSWER 4. Partial-thickness skin
loss of the dermis
Rationale: In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis
has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may
AND CORRECT ANSWERS
The nurse reviews the arterial blood gas results of a client with emphysema and notes that the
laboratory report indicates a pH of 7.30, Paco2 of 58 mm Hg, Pao2 of 80 mm Hg, and Hco3 of 27
mEq/L. The nurse interprets that the client has which acid-base disturbance?
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis - CORRECT ANSWER 3. Respiratory Acidosis
Rationale: The normal pH is 7.35 to 7.45. Normal Paco2 is 35 to 45 mm Hg. In respiratory acidosis,
the pH is low and Paco2 is elevated. Options 1, 2, and 4 are incorrect interpretations of the values
identified in the question.
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client
is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG)
monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn
and the nurse reviews the results, expecting to note which finding?
1. A decreased pH and an increased Paco22
2. An increased pH and a decreased Paco23
3. A decreased pH and a decreased HCO3-4
4. An increased pH and an increased HCO3- - CORRECT ANSWER 4. An increased pH and
an increased HCO3-
Rationale: Clients experiencing nausea and vomiting would most likely present with metabolic
alkalosis resulting from loss of gastric acid, thus causing the pH and HCO3- to increase. Symptoms
experienced by the client would include hypoventilation and tachycardia. Option 1 reflects a
respiratory acidotic condition. Option 2 reflects a respiratory alkalotic condition, and option 3 reflects
a metabolic acidotic condition.
The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30
mm Hg (30 mm Hg). The nurse monitors the client for which clinical manifestations associated with
these ABG results? Select all that apply.
1. Nausea
,2. Confusion
3. Bradypnea
4. Tachycardia
5. Hyperkalemia
6. Light-headedness - CORRECT ANSWER 1,2,4,6
Rationale: Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion
concentration that results from the accumulation of base or from a loss of acid without a comparable
loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory
system. Clinical manifestations of respiratory alkalosis include lethargy, light-headedness, confusion,
tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness
and tingling of the extremities. Hyperventilation (tachypnea) occurs. Bradypnea describes respirations
that are regular but abnormally slow. Hyperkalemia is associated with acidosis.
The nurse is caring for a client with several broken ribs. The client is most likely to experience what
type of acid-base imbalance?
1. Respiratory acidosis from inadequate ventilation
2. Respiratory alkalosis from anxiety and hyperventilation
3. Metabolic acidosis from calcium loss due to broken bones
4. Metabolic alkalosis from taking analgesics containing base products - CORRECT ANSWER
1. Respiratory acidosis from inadequate ventilation
Rationale: Respiratory acidosis is most often caused by hypoventilation. The client with broken ribs
will have difficulty with breathing adequately and is at risk for hypoventilation and resultant
respiratory acidosis. The remaining options are incorrect. Respiratory alkalosis is associated with
hyperventilation. There are no data in the question that indicate calcium loss or that the client is taking
analgesics containing base products.
The nurse is planning care for a client with acute otitis media. To reduce pressure and allow fluid to
drain, the nurse anticipates that which measure would most likely be recommended to the client?
1. Strict bed rest
2. A myringotomy
3. A mastoidectomy
4. Diphenhydramine - CORRECT ANSWER 2. A myringotomy
,Rationale: A myringotomy is a surgical procedure that will allow fluid to drain from the middle ear
and may be necessary to treat acute otitis media. Strict bed rest is not necessary, although activity may
be restricted. Additionally, bed rest would not assist in reducing pressure or allowing fluid to drain. In
some recurrent and persistent cases, the mastoid bone is removed or partially removed for chronic
otitis media. Diphenhydramine is an antihistamine with antiemetic properties.
The nurse is instructing a client with Parkinson's disease about preventing falls. Which client
statement reflects a need for further teaching?
1. " I can sit down to put on my pants and shoes."
2. " I try to exercise everyday and rest when I'm tired."
3. " My son removed all loose rugs from my bedroom."
4. " I don't need to use my walker to get to the bathroom." - CORRECT ANSWER 4. " I don't
need to use my walker to get to the bathroom."
Rationale: The client with Parkinson's disease would be instructed regarding safety measures in the
home. The client needs to use a walker as support to get to the bathroom because of bradykinesia. The
client needs to sit down to put on pants and shoes to prevent falling. The client needs to exercise every
day in the morning when energy levels are highest. The client needs to have all loose rugs in the home
removed to prevent falling.
A client is diagnosed with conjunctivitis, and the nurse provides information to the client about the
use of contact lenses. Which statement by the client would indicate the need for further information?
1. "I would not wear my contact lenses."
2. "New contact lenses need to be obtained."
3 ."My old contact lenses need to be discarded."
4. "My contact lenses can be worn if they are cleaned properly." - CORRECT ANSWER 4.
"My contact lenses can be worn if they are cleaned properly."
Rationale:If the client wears contact lenses, the client needs to be instructed to discontinue wearing
them until the infection has cleared completely. Securing new contact lenses will eliminate the chance
of reinfection from contaminated contact lenses and will also lessen the risk of a corneal ulceration.
The nurse is assessing a client who is experiencing seizure activity. The nurse understands that it is
necessary to determine information about which items as part of routine assessment of seizures?
Select all that apply.
1. Postictal status
, 2. Duration of the seizure
3. Changes in pupil size or eye deviation
4. Seizure progression and type of movements
5. What the client ate in the 2 hours preceding seizure activity - CORRECT ANSWER 1,2,3,4
Rationale: Typically seizure assessment includes the time the seizure began, parts of the body
affected, type of movements and progression of the seizure, change in pupil size or eye deviation or
nystagmus, client condition during the seizure, and postictal status. Determining what the client ate 2
hours prior to the seizure is not a component of seizure assessment.
A client with multiple sclerosis tells a home health care nurse about having increasing difficulty in
transferring from the bed to a chair. What is the initial nursing action?
1. Observe the client demonstrating the transfer technique.
2. Start a restorative nursing program before an injury occurs.
3. Seize the opportunity to discuss potential nursing home placement.
4. Determine the number of falls that the client has had in recent weeks. - CORRECT ANSWER
1. Observe the client demonstrating the transfer technique.
Rationale: Observation of the client's transfer technique is the initial intervention. Starting a
restorative program is important but not unless an assessment has been completed first. Discussing
nursing home placement would be inappropriate in view of the information provided in the question.
Determining the number of falls is another important intervention, but observing the transfer
technique needs to be done first.
The evening nurse reviews the nursing documentation in a client's chart and notes that the day nurse
has documented that the client has a stage II pressure ulcer in the sacral area. Which finding would the
nurse expect to note on assessment of the client's sacral area?
1. Intact skin
2. Full-thickness skin loss
3. Exposed bone, tendon, or muscle
4. Partial-thickness skin loss of the dermis - CORRECT ANSWER 4. Partial-thickness skin
loss of the dermis
Rationale: In a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis
has occurred. It presents as a shallow open ulcer with a red-pink wound bed, without slough. It may
