NUR 425 Exam 1: Medical Surgical V1 - Arizona College
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient’s arterial blood gas results show a pH of 7.30 and a PaCO2 of 50 mmHg. Which condition is the
patient experiencing?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Ans: A
Explanation: Respiratory acidosis is characterized by a low pH and an elevated carbon dioxide level.
This condition often occurs when the lungs are unable to effectively remove CO2 from the body. Nurses
should monitor for symptoms such as confusion, lethargy, and labored breathing. Diagnostic
confirmation relies on finding a pH below 7.35 and a PaCO2 above 45 mmHg. The primary intervention
involves improving ventilation to restore gas exchange balance.
2. Which clinical manifestation is most indicative of metabolic acidosis in a patient with diabetic
ketoacidosis?
A. Bradypnea
B. Hypertension
C. Kussmaul respirations
D. Increased appetite
Ans: C
,Explanation: Kussmaul respirations are deep, rapid breaths that represent a compensatory mechanism
for metabolic acidosis. The body attempts to blow off excess carbon dioxide to raise the blood pH level.
This breathing pattern is commonly seen in patients with severe hyperglycemia and ketone
accumulation. Nursing care focuses on monitoring respiratory effort and administering intravenous
fluids. Successful treatment results in the normalization of bicarbonate levels and the resolution of
acidemia.
3. A patient is hyperventilating due to severe anxiety. Which acid-base imbalance is the nurse likely to
observe?
A. Respiratory Alkalosis
B. Metabolic Alkalosis
C. Metabolic Acidosis
D. Respiratory Acidosis
Ans: A
Explanation: Respiratory alkalosis occurs when excessive carbon dioxide is exhaled during rapid
breathing or hyperventilation. The loss of CO2 causes the blood pH to rise above the normal threshold of
7.45. Patients may complain of lightheadedness or tingling in their extremities during these episodes.
Encouraging the patient to breathe slowly or into a paper bag can help retain carbon dioxide. The goal is
to correct the respiratory rate and stabilize the patient’s anxiety.
4. Prolonged vomiting or nasogastric suctioning can lead to which of the following acid-base imbalances?
A. Metabolic Alkalosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
, D. Respiratory Acidosis
Ans: A
Explanation: Metabolic alkalosis is caused by the loss of gastric acid through vomiting or continuous
suctioning. The loss of hydrogen ions leads to an increase in serum bicarbonate levels. Patients might
display signs such as irritability, tremors, or muscle cramping. Nurses must monitor electrolyte levels
and provide replacement fluids as prescribed. Restoring the acid-base balance requires addressing the
source of the fluid and ion loss.
5. Which physical assessment finding is most characteristic of fluid volume deficit in an elderly patient?
A. Dependent edema in the lower extremities
B. Poor skin turgor over the sternum
C. Jugular venous distension
D. Bounding peripheral pulses
Ans: B
Explanation: Fluid volume deficit leads to decreased skin elasticity, though it is best assessed over the
sternum in older adults. Dehydration causes a decrease in total body water and circulating blood volume.
Clinical signs include dry mucous membranes, dark urine, and orthostatic hypotension. Nurses should
encourage oral intake and monitor intake and output closely. Rehydration is considered successful when
the patient exhibits stable vital signs and adequate urine output.
6. When assessing a patient with fluid volume excess, which finding should the nurse anticipate?
A. Crackles in the lung bases
B. Flat neck veins when supine
C. Decreased central venous pressure
Updated and Latest Questions and Correct Answers with
Rationale
1. A patient’s arterial blood gas results show a pH of 7.30 and a PaCO2 of 50 mmHg. Which condition is the
patient experiencing?
A. Respiratory Acidosis
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic Alkalosis
Ans: A
Explanation: Respiratory acidosis is characterized by a low pH and an elevated carbon dioxide level.
This condition often occurs when the lungs are unable to effectively remove CO2 from the body. Nurses
should monitor for symptoms such as confusion, lethargy, and labored breathing. Diagnostic
confirmation relies on finding a pH below 7.35 and a PaCO2 above 45 mmHg. The primary intervention
involves improving ventilation to restore gas exchange balance.
2. Which clinical manifestation is most indicative of metabolic acidosis in a patient with diabetic
ketoacidosis?
A. Bradypnea
B. Hypertension
C. Kussmaul respirations
D. Increased appetite
Ans: C
,Explanation: Kussmaul respirations are deep, rapid breaths that represent a compensatory mechanism
for metabolic acidosis. The body attempts to blow off excess carbon dioxide to raise the blood pH level.
This breathing pattern is commonly seen in patients with severe hyperglycemia and ketone
accumulation. Nursing care focuses on monitoring respiratory effort and administering intravenous
fluids. Successful treatment results in the normalization of bicarbonate levels and the resolution of
acidemia.
3. A patient is hyperventilating due to severe anxiety. Which acid-base imbalance is the nurse likely to
observe?
A. Respiratory Alkalosis
B. Metabolic Alkalosis
C. Metabolic Acidosis
D. Respiratory Acidosis
Ans: A
Explanation: Respiratory alkalosis occurs when excessive carbon dioxide is exhaled during rapid
breathing or hyperventilation. The loss of CO2 causes the blood pH to rise above the normal threshold of
7.45. Patients may complain of lightheadedness or tingling in their extremities during these episodes.
Encouraging the patient to breathe slowly or into a paper bag can help retain carbon dioxide. The goal is
to correct the respiratory rate and stabilize the patient’s anxiety.
4. Prolonged vomiting or nasogastric suctioning can lead to which of the following acid-base imbalances?
A. Metabolic Alkalosis
B. Metabolic Acidosis
C. Respiratory Alkalosis
, D. Respiratory Acidosis
Ans: A
Explanation: Metabolic alkalosis is caused by the loss of gastric acid through vomiting or continuous
suctioning. The loss of hydrogen ions leads to an increase in serum bicarbonate levels. Patients might
display signs such as irritability, tremors, or muscle cramping. Nurses must monitor electrolyte levels
and provide replacement fluids as prescribed. Restoring the acid-base balance requires addressing the
source of the fluid and ion loss.
5. Which physical assessment finding is most characteristic of fluid volume deficit in an elderly patient?
A. Dependent edema in the lower extremities
B. Poor skin turgor over the sternum
C. Jugular venous distension
D. Bounding peripheral pulses
Ans: B
Explanation: Fluid volume deficit leads to decreased skin elasticity, though it is best assessed over the
sternum in older adults. Dehydration causes a decrease in total body water and circulating blood volume.
Clinical signs include dry mucous membranes, dark urine, and orthostatic hypotension. Nurses should
encourage oral intake and monitor intake and output closely. Rehydration is considered successful when
the patient exhibits stable vital signs and adequate urine output.
6. When assessing a patient with fluid volume excess, which finding should the nurse anticipate?
A. Crackles in the lung bases
B. Flat neck veins when supine
C. Decreased central venous pressure
